The link between high fat foods and asthma

The following originally appeared at Healthcentral.com/asthma on May 16, 2011.

Can Eating High-Fat Foods Trigger Asthma?

American's love Big Macs, Whoppers, French fries, onion rings and deep fried chicken.  These are convenient foods that are simply delicious.  Yet the old saying goes, "If it tastes good, it's probably not good for you."

Now we already knew such high-fat foods are bad for your heart.  Yet new evidence suggests they may also be bad for your lungs. 

A study completed by Australian researchers in 2010 tested asthmatics before and after eating a meal, and determined that lung function was worse after eating a high-fat meal.

If that wasn't bad enough, the study also concluded that high-fat foods also made it so asthma rescue medicine (like Albuterol) worked less well. 

Scientists aren't sure why this is, yet there are theories.  One theory suggests that your asthmatic immune system might recognize saturated fat as an enemy and promptly acts to rid it from your system. 

This response results in an increase in markers of inflammation such as leukotrienes and hystamine, and these increase inflammation in your respiratory tract.  This causes muscles lining your air passages to constrict, and thus an asthma attack is the result.

Perhaps due to the increased inflammation, asthmatics who used their rescue medicine after eating a high-fat meal did not get as much relief as those who ate low-fat meals.   Likewise, lung function improved less in subjects who used their rescue medicine after eating high-fat meals.

Obviously asthma rates have increased incrementally in the U.S. and other western nations over the past 20 years.  This new theory suggests one of the factors might be the high-fat foods we put into our bodies.

I've also read other studies that suggest that if you're exposed to something that triggers inflammation in your lungs, and exposed to it often enough, the inflammation may become permanent.  Thus, asthma is developed.

It's studies like this that remind us that the way we eat may determine the lives we live.  If you want to prevent asthma, or prevent an asthma flare, it may be a good idea to eat a healthy diet.

Does that mean we asthmatics should never eat great tasting, convenient and high-fat foods?  Absolutely not.  Yet it's good to know the facts, and it's good to know what foods might not be good for us.

Delayed gratification

I am one of many who will contend that one of the problems with our society, and why the economy is doing so poorly lately, is that so few Americans believe -- or even comprehend -- the idea of delayed gratification. 

We live in a society where we want everything, and we want everything now.  We want the best house and the best car and the best toys for our kids and the best toys for ourselves.  Many of us are even willing to mortgage everything we have in order get all this stuff. 

Delayed gratification, defined, means that you do just the opposite:  you wait.  You wait to buy something until you can pay cash for it.  In this way, you can get twice as much and enjoy it twice as much. 

Yet many of us can't wait.  We think we need things right now.  This was the topic of a research project completed in the 1960s and 1970s (and discussed here at science daily) where pre-school kids were given a marshmallow and told if they wait five minutes before they ate it they could have another marshmallow.  "Some of the children resisted, others didn't."

A new study followed up with the kids tested in the original study and the results showed that the same kids who resisted eating the marshmallow when they were kids showed that they were still skilled at delayed gratification as adults. 

Kids who couldn't resist the temptation to eat that marshmallow (or cookie, or candy bar) as kid were equally as likely to be unable to resist the temptation of immediate gratification as an adult.  Which almost makes one wonder if the skills of gratification are inert and genetic as opposed to environmental.

Of equal interest, the study showed this:

Brain imaging showed key differences between the two groups in two areas: the prefrontal cortex and the ventral striatum.

Researchers say this is the first time they've found "specific" brain differences associated with gratification.  This might help them, they contend, to learn more about and how to treat people with addiction -- like addiction to stuff.

I learned about the above study from this article in the Blaze.

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STAT: A word that is often abused

The word "STAT" comes from the Latin word staim which means immediately.  So stat is essentially an abbreviation of the old word.  It's common for the English to be lazy with speech, and thus is how the word stat was formed.

Proper use of the word is either capitalized or not capitalized. 

Essentially, when someone is called STAT it means that person is needed immediately.  Unfortunately, however, the word "immediately" does not denote what the person is needed for.  So you can be called STAT because your services are desired to save a life, or  you could be called so the doctor can get his EKG results quick so he can see it before he goes home for dinner.

Ideally you'd think the word STAT would be used for life and death situations, such as the following. :

• RT STAT to ER..... we have a patient in respiratory distress
• RT STAT to 244.... we have a patient in V-tach
• RT STAT to ICU...  we have a patient with a heart rate of 27
• RT STAT to ER...  we have a patient who can't breathe

Realistically, the above plus the following are more likely to occur in tandem:

• RT STAT to ER.... EMTs are 20 minutes out with a cardiac arrest
• RT STAT to 244.... Dr. Jones wants an EKG done before he goes home, pt is fine
• RT STAT to ambulatory surgery... Dr. wants pre-op EKG done
• RT STAT to CCU... RN wants EKG to see what rythm patient is in

Actually, I have recent pages such as the following:

• STAT EKG in 2234 in two hours
• STAT ABG in an hour on the vent patient

With such a vague definition, and with such frivolous use of the word statim or STAT, the word has lost much of it's luster and RTs have become deconditioned to the word.  When an RT may be needed immediately, he may be inclined to finish his last bite of steak before sauntering to where he's needed.

He may also be written up for responding to a code overly relaxed and in a non-urgent manner.

What is intubation?

Intubation is where we insert an endotracheal tube into the airway of a patient to the lungs in order so that we can breathe for that patient.  (to watch a video click here)

Indications for intubation may include:

1.  During surgery.  Your breathing may be stopped with anesthetic medicine and your breathing will be assisted with a ventilator.

2.  Drug overdose:  The patient took medicine that made him so relaxed that he is in danger of vomiting and inhaling that vomit (aspiration).  In this way, intubation may be indicated to protect the patient's airway.

3.  Neuromuscular paralysis:  Some diseases cause the patient to be unable to breathe, and in these cases the patient will require intubation.  If the disease is permanant or long term, a tracheostomy may be inserted.

4.  Trauma:  The patient has been in an accident and is unable to breathe on his own.  In these cases intubation may be indicated.

5.  Labored breathing:  The patient has a disease like asthma, COPD, lung cancer, pneumonia, heart failure, etc. and is having severe trouble breathing.  We can intubate these patients so we can breathe for them while we work our magic to fix the underlying cause.

6.  Heart attack or head trauma:  In these instances, we may need to assist the patient with their breathing so that we can rest their bodies in order to allow our medicines to work their magic.

Most intubations are short term, just in long enough until the surgery is complete, or until the disease process is resolved.  When a patient is intubated the patient will either be ventilated (breathed for) by an Ambu bag or a ventilator.

When this tube is removed it is called extubation.

What is an ambubag? (coming soon)

What is a ventilator? (coming soon)
History of respiratory therapy (coming soon)

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Do Rapid Response Teams work?

Hypothesis:  I personally believe that the more people caring for a patient, and the more people assessing the patient, the better off the patient will be.  It is for this reason I think Rapid Response Teams are a good method of preventing patients from going into respiratory and/or cardiopulmonary arrest, and thereby improving patient outcomes by preventing the need to transport patients to the Critical Care Unit (CCU).

Question:  Do Rapid Response Teams really work?  This was a question recently taken up by RTmagazine.com, "Are Rapid Response Teams the Answer?"  The article, written by Michael V. Frey, RRT/ NPS, creates several good arguments that the answer to the question may be no.

What is a Rapid Response Team (RRT)?  It's a team of experts who respond to the patients bedside when the patient doesn't look quite right to the attending nurse or physician.  The team consists of CCU nurse, Nursing Supervisor, Respiratory Therapist, Physician (if one is available) and the patient's nurse.  The goal is to be proactive and do what is necessary to prevent the patient from getting worse.  

Why were RRTs believed to be a good thing?  According to Frey

1.  Most floor nurses lack critical care experience

2.  Some nurses were hesitant to do proactive therapies without a physician's  order.  This is important because sometimes it takes a while for the physician to call back, and the patient needs something done right now.  For our small town hospital, I think this was the key to forming an RRT.  There were many times a nurse wouldn't treat the patient that needed immediate attention just because she didn't want to do something without an order.  RRTs eliminated this, and the end result has prevented such patients from needlessly ending up in the CCU.  This I would consider the most valid reason for an RRT.  

The following studies seem to show RRTs work, as mentioned by Frey:

• 50% reduction in the occurrence of cardiac arrest outside the ICU
• 17% decrease in the incidence of cardiopulmonary arrests (6.5 versus 5.4 per 1,000 admissions)⁴;
• Severe postoperative adverse events (ie, respiratory failure, stroke, severe sepsis, acute renal failure) reduced by 58%⁵;
• Emergency ICU admissions reduced by 44%⁵;
• Postoperative deaths reduced by 37%, and mean duration of hospital stay decreased from 23.8 to 19.8 days in surgical patients⁵; and
• There has been a decrease in the number of unnecessary transfers to a higher level of care by a mean of 30%.⁶

The argument against RRTs:  (According to Frey)

1.  RRTs are a band aid solution to a bigger problem of nurses not understanding the needs of their patients.

2.  Some patients are on the medical/ surgical floor, or step down unit, only because there are no beds available in the CCU.  It's these patients who are at greatest risk for deterioration.  

3.  Due to cost cutting, some patients are moved our of CCUs and to step down units.  These patients are also at high risk for deterioration.

Conclusion;  I think the general conclusion is that RRTs work.  My experience with them is they work, and I noted one very good reason above:  At a small hospital, we don't have physician coverage 24 hours a day, and therefore RRTs sort of fill the gap between observation of a deteriorating patient and communication with the physician.  

Surely, however, there are methods that could be improved.  For example, if the CCU nurse already has several critical patients, it's difficult for that person to be pulled away from his already critical patients to care for a patient of another nurse.  However, all in all, I think the teams are working, and the statistics show they are working.  

What do you think?

What is a blood gas?

A blood gas is a test we use to determine how much oxygen and CO2 are in the patient's blood.  It's a blood draw where you insert a needle into the patient's radial artery in the wrist area, bracheal artery in the antecubital area (the backside of the elbow) or the femoral artery in the groin (thankfully we don't use this area too often).

About 90 percent of the time we draw this blood from the wrist.  We draw arterial blood because this blood is  freshly oxygenated blood from the lungs on its way to tissues.  We want to know how much oxygen is in this blood.  If oxygen is low then we may choose to supply the patient with supplemental oxygen.  We can do this with a nasal cannula or a variety of masks.

If the CO2 is high we may need to assist the patient with his ventilations in order to help the patient blow off this CO2.  The reason CO2 gets high is because the patient is not taking good enough breaths.  He may be pooping out because his lungs are diseases.  In this case, we use his CO2 level to help us determine what we can do to help him.

Another thing an ABG does is help us determine the acidity (pH) of the blood.  If a patient is in severe respiratory distress his blood may become very acidotic.  If this happens, we may need to help the patient breath so that we can get his pH back to normal.

This blood test can also help a doctor diagnose some diseases. For example, if the CO2 is chronically elevated this can be a classic sign of chronic bronchitis or emphysema.  Too see a video of an ABG being drawn you can click here.

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Have you ever switched from Advair to Symbicort

Your Question:  Have you ever switched from Adair Symbicort ? If so were the results the same, or is one better than the other?

My humble answer:  As of right now there are no FDA approved generics for Advair or Symbicort.  I did switch from Advair to Symbicort once.  As far as control of my asthma it was the same either way.  The Symbicort was nice in that it acts like a quick relief inhaler opening my airways immediately, as opposed to 15 mintutes for Advair.  This was nice.  However, Symbicort made my heart pound while Advair never did that.  So in my case I switched back to Advair.  The medicine in both are "relatively" the same, so from the expert standpoint I think which one works best is a matter of personal or professional preference.  In my case, I prefer Advair.  I do know quite a few asthmatics who prefer Advair and also quite a few who prefer Symbicort.  There' salso another option available along this line of medicine called Dulera.  I tried that once too and it was basically the same as Symbicort.  So that's my own personal experience with Advair and Symbicort.

Are expired asthma medicines safe to use?

The following was originally published at HealthCentral.com/Asthma on May 23, 2011:

Is it OK to Use Expired Asthma Medicines?

You found your asthma medicine sitting at the bottom of your sock drawer and now you're wondering:  Can I still use it?  Is it safe?  Will it still work?  Is it okay to use expired asthma medicines?

Asthma medicine has a tendency to be expensive. One Advair Discus costs over $100 just for one month.  Even with good health insurance, I pay about $1 for each Singulair pill.  The cost of other asthma medicines can add up to.  

If you're normal like me, you lose your inhalers.  I just opened three brand new Ventolin inhalers in the past week, and I already can't find two of them.  I did find one when I cleaned under the bed, yet it was dated January 2009.

While it's recommended every asthmatic have a rescue inhaler like Ventolin on hand at all times, and that we replace it every year, I know of many of you guys who have one yet it's done nothing but sit at the bottom of your sock drawer.  Now you're short of breathe and wondering, can I still use it?

More recently I received a question about how long Advair is good for.  This person had no insurance and wanted to know if it was safe to use an Advair that was opened but expired four months ago.  She also had one Advair that was expired but was never opened.

Are these medicines safe?  Would they still be effective if used?

When I was a kid I'd lose inhalers all the time.  If the one I was using ran out, and I for some reason didn't tell my mom I needed a new one, and I was having a raging asthma attack in the middle of the night, I'd rummage my room hoping to find a lost one.

Then I'd find one and take a puff.  If you've ever taking a hit off an expired Ventolin inhaler you'd know it, because it tastes like rotten mints.  Yet you wouldn't mind so much, because it still helped you get your breath back.

More recently I did some research to find out what the scientific evidence was regarding old and expired medicine.  I asked the pharmacist where I work, and he gave the old stand-by and political response, "It's good for up to a year."

Yet that didn't satisfy me.  So I continued my search for answers.  What I learned is that science has pretty much proven that no asthma medicine will harm you if you use it beyond its expiration date.

So in that sense you can feel okay about using expired medicines.  I mean, I'm proof expired asthma medicines don't kill.  If nothing else, I've proved that many times.

As far as potency, over time asthma medicines do become less potent, although they will still work better than using nothing.  In fact, most new medicines are good for two to three years from the day they are produced so long as they remain in the original packaging.

And considering a medicine may sit on the shelf of storerooms, trucks and then pharmacies, the expiration date is generally listed as one year as of your purchase date.

So you can see there really is no scientific reasoning for that expiration date.  The medicine might still be potent for some time.  So if your package is not opened, you should be able to use older medicine (within reason of course).

However, once the original container is opened for use or dispensing, the expiration date on the container no longer applies.  In fact, according to, this ABC News post, the expiration date of a medicine is actually just the predicted date at which the drug will lose 10 percent of its potency.  

Once a medicine loses more than 10 percent of its potency it's no longer considered effective.  From that point on, it continues to lose more and more of it's potency.  Plus, if it's an an inhaler, it starts to taste nasty.

The expiration date also assumes you are storing the medicine at the recommended temperature and humidity.  Most medicine should be somewhere between 59 and 86 degrees F (15-30 degrees C) and away from light and moisture.  You'll have to check the package of your medicines to see the exact recommendations.

This means that asthma medicines should not be stored in the bathroom where

it will be exposed to high humidifiers during and after showers.  So I suppose the bathroom medicine cabinet’s not such a wise place to store your meds after all. 

While most asthma drugs are not hazardous if used after their expiration dates, the efficacy of the medicine after that date can no longer be guaranteed.  Thus, if you are using an expired medicine you may not be getting the expected results.

So, should you use those expired asthma medicines?  At least now you can make an educated decision.

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How to deal with criticism and faults

Giving criticism is something we all must do with from time to time.  The problem is, most people hate to criticize -- except behind your back -- and most people hate to be criticized.  Yet an appropriate level of criticism is essential, and can even be good if done appropriately.

Believe it or not even the ancients dealt with this topic.  If you read the Bible you'll see that it was dealt with in Matthew 18: 15-17.  Matthew writes:  "If your brother or sister sins, go and point out their fault, just between the two of you.  If they listen to you, you have won them over.  But if they will not listen, take one or two others along, so that 'every matter may be established by the testimony of two or three witnesses'  If they still refuse to listen, tell it to the church; and if they refuse to listen even to the church, treat them as you would a pagan or tax collector."

To give a good example, I had a doctor write me up recently because I was, in her words, "too relaxed in my approach to an emergency."  My initial response was anger, and that's a normal response.  My second response was to laugh it off with my boss.  Neither of us took it seriously (as you can note for yourself in this facetious post).

This doctor did not follow the rule of talking to me first.  She was tactless.

I have to be honest and tell you that when my boss comes to me and tells me I did something wrong, or a doctor didn't agree with something I did or said, I get angry.  That's almost always my first reaction.  Then I shut my mouth and listen.  Then I listen to my boss as she tells me how to do it right.

Chances are I'll leave her office upset and angry.  I might even be in a mood.  Yet there's also another thing that almost always happens as a result of this criticidsm:  it gets me to thinking.  Somehow and someway I will make some change that will make me better.  As a return, this will make the department better.

So a good manager who follows the appropriate steps can use criticism to make her workers better, and make her department better.  Yet for the sake of God and the sake of morale, she better not come complaining to us about trivial things, and she better not go to her boss to complain about me before she talks to me.

That was the mistake my doctor friend made.  She failed to take the appropriate steps.  Her soft skills in this regard were severely lacking.  This is a problem I face with her -- and so do my fellow workers -- on a regular basis.  Yet we bite our tongues and deal with it.  Sometimes we get angry, yet mostly we laugh it off.

I can guarantee that something will change after just about every criticism.  If I don't make myself a better therapist, I'll use that energy to make myself better at avoiding the critical person.  I will avoid that person like the plague.  I will become quite adept at it.

If I cannot avoid the annoying criticizer, then I will find a way of only speaking to that person on a professional basis.  Thus, if you me how I like that doctor, I will say:  We have a good professional relationship".  If I say that about you, then you know I don't like you.  Although I've said it only three or four times in my 15 years as an RT.

My point here is that sometimes you must approach someone with criticism.  If you do it appropriately, good things can result.  Yet if you do it inappropriately, you become the fool.

RT Creed: Fear and Stress are necessary

Date:  7/11/62

To: Sim body, Director of IT Services

From:  Dr. Na buddy, ER physician, medical director

Re:  Relaxed ITs

Memo:  It has been observed that many of our fine Inhalation Therapists (ITs) have been reporting to codes and over head pages in a relaxed mode of behavior.  Just yesterday I witnessed two ITs enter the ER in a lackadaisical manner, relaxed and acting as though nothing was going on.  The truth was that the patient needed a STAT Bronchosol breathing treatment or he was going to die.  It was essential we got the bronchodilator into the patient's system before we inserted the chest tube to make sure the air got out of the patient's chest faster.

For the future, we recommend all ITs reporting to the ER be all stressed, sweaty, and have their tongues lagging from their mouths out of pure exhaustion when reporting to emergency calls.  We want to make sure the IT is on the same mental footing as the nurses and doctors so they can make the essential decisions out of panic and fear rather than from a relaxed state of mind.  Please consider this an unwritten policy at this institution. 

Also, I have been alerted that many of your fine ITs have still been talking to patients during breathing treatments.  We find this affects the deposition of the medicine and is causing the patient to feel too much at home and relaxed.  Again, we find that stress and anxiety help with the lung healing process.  Again, please consider this an unwritten policy at this institution.

Thank you for your attention in this regard

What is a crash cart

A crash cart ready for action

A crash cart is a cart that has all the emergency equipment and medicine emergency medical professionals need to attempt to save the life of a person who's not breathing or is in a life threatening cardiac rhythm.

Usually the cart is compiled of a tool cart.

The cart is on wheels so it can be transported to different areas where an emergency will be.  It's generally available in case a patient goes into respiratory or cardiopulmonary arrest (heart and breathing stop), or for emergencies often referred to as codes or code blues.

Yet the cart is also used to treat impending or active symptoms that could lead to more serious complications if not treated immediately, such as new onset symptomatic supraventricular tachycardia.

It's also carted to the bedside of patients who don't look quite right, and in this case a rapid response team is called.  The goal here is to avert an impending emergency situation by treating early signs and symptoms of failure, such as mental changes, vital sign changes, and erratic heart rhythms.  (Learn when to call a doctor by clicking here).

On top the cart is usually a heart monitor with defibrillators to monitor the heart and to shock the patient if required.

Next to the heart monitor is a box or bag with respiratory therapy equipment needed to intubate and manage the airway of a patient should the patient stop breathing, or should the breathing become inadequate.   Also up on top is a clipboard one nurse will use to record.  This nurse if often referred to as the recorder.

Sometimes the respiratory equipment is locked inside one of the drawers, although I think it's best on top the cart for easy access in an emergency.

In the drawers are suction equipment and an assortment of emergency medicines for all sorts of situations that might arise in an emergency situation.  It will have Advanced Cardiac Life Support medicine like epinepherine, atropine, amioderone, cardizem, dopamine, etc.  It may also have Albuterol in case the patient is having trouble breathing and nebulizer equipment.

When there is an emergency situation most hospitals are now universal in calling overhead "Code Blue!"  When this is called all members of the code team are to report to the specific location, with one member bringing the crash cart.

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42 undeniable truths about healthcare

Surely some of these may be controversial, as the truth often is.  Yet the following are the 42 undeniable truths of the healthcare industry:

1. All medical professionals have an inert yearning to be self reliant and use the education and experience they've obtained
2. The way to improve the healthcare system is to get the government out of it.
3. The RT (doctor, RN) at the bedside knows what's best for the patient more so than an order set
4. Order sets are are socialistic and are an excuse for doctors and nurses to be lazy
5. Protocols are capitalistic and encourage thought
6. I am not arrogant
7. Supervisors quickly forget what it was like to work on the patient floors
8. The way to reduce healthcare costs is to make everyone pay for each service
9. DRGs increase medical waste and lying about a diagnosis just to assure reimbursement
10. Keystone Committees are an attempt to enforced socialized medicine
11. Evidence Based Medicine is a nice way of saying everyone must do it the same
12. Intensity of Service is an excuse for doctors and nurses to lie
13. Quality Assurance Analyzers are only needed because the government is involved in healthcare
14. Tylenol is not a default cure for all that ails a patient
15. Throwing everything at a patient in the hopes something works is not common sense
16. Regulating hospitals does not make for better healthcare, it makes for fewer hospitals
17. We need more humor in healthcare
18. Bronchodilators treat shortness of breath due to bronchospasm and nothing more
19. They hypoxic drive theory was a hoax created to make respiratory therapists relevant in the 1960s
20. Xopenex is the same as Albuterol with the same effect and same side effects. 
21. IPPB does not work better than patient coaching with an incentive spirometer to treat and prevent atelectasis, and studies prove this.
22. Too many patients are put on a ventilator out of panic rather than logic
23. Much of what respiratory therapists do is either a waste of time or delays time
24. Dyspnea with exertion is not asthma and should not be treated with a bronchodilator
25. If it's audible it's not bronchospasm
26. If it's coarse it's rhonchi.
27. The best way to hear lung sounds is to use a stethoscope on the patient's chest
28. The best way to assess a patient is by touching the patient (not by talking over the phone)
29. It's immoral to NT suction an awake, alert and orientated patient
30. Respiratory therapists are not ancillary staff (they are professionals knowledgeable in an area beyond the scope of most physicians)
31. Doctors and nurses who are stupid about respiratory therapy don't know they are stupid about respiratory therapy and most will never admit it
32. If you refuse to do a breathing treatment that isn't indicated you are not being lazy
33. BIPAP does not help fulmonating edema by forcing fluid out of the lungs, it reduces fulmonating edema by reducing venous return and therefore reducing cardiac output so the heart can catch up
34. Supplemental oxygen will not treat anemia, and is not indicated just because someone has chest pain because if all the seats on a bus are full, the extra passengers won't get a seat
35. The truth hurts before it makes you better
36. Scientific evidence disproves that albuterol will treat pneumonia, CHF, rickets, cystic fibrosis, lung cancer, pulmonary embolism, pneumothorax, pleural effusion, detox, dehydration, and even emphysema and chronic bronchitis.  It only benefits these patients if asthma (hyperactive airways) is a component of said ailment.
37. All that wheezes is not asthma
38. All dyspnea is not asthma
39. If a patient is obnoxious, annoying, belligerent, rancid, or has maggots, respiratory services are not automatically indicated
40. Order sets and physician convenience are not indications for using the word stat.  
41. The clinical picture doesn't always match the science (i.e., hypoxic drive hoax, hoaxenex, and studies showing inhalers work the same as nebulizers)
42. Some studies are conveniently ignored by the medical community (such as beta adrenergic receptors don't exist in lung parynchema and renal tibules.)

Up with IPPB

As my regular readers know, I am not a fan of the IPPB as I wrote in my post "Down with IPPB."  Yet if you are ordered to use it you might as well do it right. 

For this reason I approached one of my fellow RTs -- Jane Sage --who's been working in the field since the mid-1980s.  She provides us with the following IPPB wisdom:

Many of our newer respiratory therapists don't know this, but that little green IPPB (Intermittent Positive Pressure Breathing) machine that sits in the corner of storage rooms collecting dust used to be ordered for admitted patients like Ventolin is ordered today.  

Those little machines first hit the market in the 1950s and were your first positive pressure ventilators.  I bet you didn't know that.  The problem with using this pneumatic device as a ventilator is that you were forcing a set pressure into a patient and there were no alarms.  Likewise, you had no idea actual pressure you were using, and you had no idea what volumes you were pushing into the patient.

If you ever watch old episodes of that old movie called "Emergency" from back in the 1970s you can see the IPPB used as a ventilator.  I don't know if you've ever heard of that old show, but I used to enjoy watching it, even if it was somewhat medically inaccurate.  For instance, every time CPR was given the patient would instantly wake up and be fine and walk off.  I've never seen that in real life, yet I digress.

So as better ventilators were invented, such as the Emerson and MA1 volume ventilators,  the IPPB was released from it's duty as a ventilator. Yet much like the makers of baking powder tried to find other ways of re-marketing their product, so did the makers of the IPPB machine. Doctors were convinced that IPPB therapy would benefit every patient admitted with a respiratory disease.  This was already going on in the 1950s, and it continued to the 1970s.   

It was believed that the positive pressure breaths from this machine would re-open resistant alveoli and benefit post operative patients, and therefore prevent and treat atelectasis.  It was also believed it would force bronchodilators deeper into the lungs, and enhance the effect of this therapy.  So IPPBs were used for just about every patient.  

When we had paralyzed patients ordered to take this therapy, or stroke patients, we used to use a special mouthpiece and we'd hold it over their mouths for the entire treatment. 

In fact, it became such a common device that in some places there were clinics where several IPPB machines were bolted to tables and COPD patients lined up for their daily IPPB treatment.  The patient would sit down and get his treatment.  When he was finished the circuit was replaced with a new one and the next patient sat down.

Yet then studies were done to show that the IPPB could actually do more harm than good to some patients with lung disease.  For example, if an emphysema patient had blebs, too high of a pressure could pop a bleb and cause an even greater problem, and even death. It was also learned that IS therapy was equally as effective as IPPB, that the pressures required to prevent atelectasis were rarely reached, and IPPB therapy actually made bronchodilators work less well, not more.  So IPPBs slowly declined, so that they are rarely ever ordered today.  

By the 1990s the IPPB machine was used for post operative patients to treat atelectasis.  Yet by the late 1990s newer RTs weren't taught about this machine in RT school as most hospitals phased them out altogether.  RT teachers didn't want to spend quality time teaching about a device that was seldom used. 

So by the 2000s the device was still ordered on occasion, yet when it was ordered the therapy wasn't provided adequately by poorly trained clinicians.  Yet I contest to this day that in certain conditions IPPB therapy can be very beneficial, and it's not above me to recommend it from time to time on the right patient.

Usually these patients will be post operative patients who aren't taking adequate breaths and are an impending respiratory distress waiting to happen.  Using the IPPB for these patients can help to open those resistant alveoli and prevent the patient from buying a ventilator.

If you are ordered to use it you should know how to use it correctly.  If you don't use it correctly it's nothing more than a glorified incentive spirometer.  So, how do you use it correctly?  How do you know if the patient is using it correctly?

First, you dial in the settings.  A good place to start is a Peak Inspiratory Pressure (PIP) of 10 and a flow of 10.  The sensitivity is usually set at about five.  Then you adjust the settings to meet the demands of the patient.  Ideally, PIP should never exceed 15.  Rarely did I ever have to go higher.

You fill the cup on the circuit with whatever medicine is ordered, usually it's Ventolin or Xopenex.  During the 1980s we usually used Alupent, yet that medicine has been since phased out because it has a greater cardiac effect than today's watered down bronchodilators.  Back in teh 1950s ethyl alcohol was used for heart failure, Isuprel was a bronchodilator used for asthma and COPD, and mucomyst was used as a mucus thinner in COPD and CF patients.  Yet now it's usually Ventolin or Xopenex.  

Then you tell the patient to place the mouthpiece between his lips, close his mouth around it, and to start to inhale.  Yet you will want to tell the patient to allow the machine to fill his lungs with air.  When the set pressure is met, the expiratory cycle will be triggered and the patient can exhale. 

To know the patient is using the device correctly you watch the pressure gauge.  When the patient triggers the breath the pressure gauge should go negative for a second (like to -5 cwp) and then it should go positive.  The pressure should gradually be increased until the expiratory cycle has begun.

Now, if the pressure goes way negative, such as to negative 10 or 20, then you know the patient is sucking in too hard.  When this occurs the patient is using the device as a glorified incentive spirometer and you are wasting your time.  You will want to coach the patient so he is using the device correctly.

A good IPPB therapy takes time and lots of coaching.  It's okay to give the patient a break every few minutes, yet the therapy should be continued until the medicine in the medicine cup is gone. A full duration IPPB treatment should be about 10 to 15 minutes.  And I must add, since you are using pressures that could be dangerous if improperly used, the therapist must stay in the room with the patient during the entire treatment.  It's not like a neb treatment where you can leave the room if necessary.  If you leave the room, if you must leave the room, please stop the treatment.  I knew of an RT once who was fired because he left IPPB patients unattended.  Not good.  

So there you have it.  IPPB therapy may not be as in demand as it once was, yet from time to time it can be a very effective therapy for the right patient.  When used correctly, IPPB therapy can prevent further deterioration of a patient's medical condition. 

Thanks, Jane Sage

Thank you, Jane.  We always appreciate your wisdom.  We hope you're enjoying your retirement.

Also read:  The IPPB Revolution:  The history of Intermittent Positive Pressure Breathing

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Does asthma effect your sex life?

Your question:  My docter told me that my asthma will prevent me to have a proper sex life.  He said that in 7 years i'll be like a 70 year old woman when I'll be of only 24years old.  I'm still a virgin and I do not really know if this is true or not.  I'm really scared and don't know what to do.  Help?

My humble answer:  I have never heard such folly in my life.  If your doctor is telling you stuff like that then perhaps it's time to get a new doctor.  It's not true.  You should call your doctor and ask him or her to provide you with some evidence.  If he does please share.  So don't worry about it.  If you need any proof, I've struggled with asthma for 42 years and have four kids.

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What happens when asthma goes untreated?

The following was originally published at HealthCentral.com/asthma on May 3, 2011.

What Other Medical Problems Can Occur When Asthma is Untreated? 

It's said a gallant asthmatics can live a normal, active life.  Yet what happens to the goofus asthmatic who doesn't treat his asthma?  

The truth is, many goofus asthmatics are lucky and are able to escape without asthma trouble, yet far too often they end up making frequent visits to their doctor, or to the local emergency room for asthma flares.  Sometimes they simply stay home and tough it out like our Martyr Asthmatic.

While it's rare, untreated asthma can lead to serious medical problems that can make asthma even harder to control.  Consider the following worse case scenario.

Joe Goofus refuses to see his doctor, and he is too dog-gone lazy to take his Advair discus, or maybe he simply forgets to take his medicine.  He also refuses to avoid his asthma triggers. He's simply a bad asthmatic patient.

So after sifting through dusty boxes in his basement, he makes yet another rushed trip to the emergency room.  His asthma is so bad this time that he needs to be admitted to the hospital.  He's put on systemic corticosteroids.

Finally after a couple weeks in prison he's released on good behavior, and he once again quits taking his asthma medicine.  He's short of breath for two weeks before he finally decides to seek help. 

He's readmitted to the hospital and put back on inhaled corticosteroids.  The cycle continues.

The following are the risks of untreated asthma:

1.  Severe Asthma:  Asthma that is not diagnosed and treated agressively with asthma controller medicines can increase the risk for lung scarring.  This is permanent damage to your lungs that can make you always feel short of breath.  It also makes it so your asthma might not be reversible when you use your rescue medicine (Ventolin or Xopenex).  This type of asthma is called severe, persistent asthma, Chronic Obstructive Pulmonary Disease (COPD) or what I like to call hard luck asthma. 

2.  Steroid side effects:  If Joe needs systemic corticosteroids long term to control his asthma, serious side effects can occur that can make it even harder to manage his asthma, such as:

• Fluid retention:  Swelling in your legs
• Increased blood pressure
• Mood swings:  Can effect how you manage your asthma
• Weight gain:  Chemicals released from fat can trigger asthma, plus obesity makes it even harder for you to get the exercise you need to manage your asthma, and keep your heart and lungs strong
• High blood sugar:  You'll now have diabetes that needs to be controlled
• Infections:  Can you imagine if you also developed pneumonia?
• Thin skin:  It easily bruises and is slow to heal. 

3.  Anxiety/ stress/ depression:  These can make it even more difficult for Joe to manage his disease, although treatable. 

4.  Muscle wasting:  His lungs become so bad he's unable to get the exercise he needs. This can greatly complicate caring for Joe.  It can lead to obesity, which complicates things even more. 

5.  Respiratory Failure:  If Joe doesn't seek help, his asthma attack might get so bad he simply poops out.  This is a serious complication that must be treated immediately.  It can lead to death.

While what I describe here is the worse case scenario, I've seen it.  It's basically self-induced hardluck asthma.  It's not pretty.  It can also be avoided. 

It's much better to be a gallant asthmatic.  It's much better to be properly diagnosed and stay on a treatment plan. 

Asthma experts have long said asthma is easiest to control when it's diagnosed right away and treated aggressively.  Now you know why.

What's better: Hard skills or soft skills?

If you're an RT you've developed skills to help you do your job, and do it well.  If not... well, then chances are you won't go far in this profession.  Some skills can be taught, and are essential to becoming a good RT.  Some skills, however, are learned, and are essential if you want to be more than just an RT.

There are two different types of skills:  hard skills and soft skills.

What are hard skill?  These are skills that can be taught and that you can improve with experience.  These include the following:

1. Setting up and managing ventilators
2. Doing breathing treatments
3. Charting on a computer
4. Performing EKGS
5. Doing ABGs
6. Setting up oxygen
7. Performing a patient assessment

What are soft skills?  These are skills that help you get along with other people, and adapt to different situations, and help you move up the professional ladder.  These are your personal attributes, like:

1. Common sense
2. Empathy
3. Sense of humor
4. Optimism
5. Sociability
6. Teamwork
7. Communication
8. Prioritizing (time management)
9. Leadership
10. Manners
11. Integrity
12. Friendliness
13. Strong work ethic
14. Critical thinking (problem solving)
15. Self confidence
16. Ability to accept criticism
17. Ability to learn from criticism
18. Flexibility (adaptability)
19. Working well under pressure

Since anyone can be taught hard skills, it's soft skills that separate the clan.  Anyone can do a breathing treatment on Mrs. Cox, but only a few can get her to like you.  Anybody can set up a ventilator, but only a few can gain the confidence of rough Dr. Bowersocks.

Anyone can join the gossip tree, yet it takes one with character and integrity to find something better to do.  Anyone can join the complainers, yet it takes one with a sense of humor to laugh it off.  Anyone can be a treatment jockey, yet it takes someone with empathy and good communication skills to truly benefit the patient.

There are a ton of treatments and EKGs to do in a short period of time.  Do you have a sense of urgency to properly prioritize and finish all your work so the next shift isn't overwhelmed?  

Can you get into a conversation with any patient?  Can you have a discussion with the complainers one moment and then an optimistic discussion with your boss the next?  Can you make any doctor or patient happy?  Does everyone like you?  If so, then you have good soft skills.

If your boss ever decides to get rid of a few RTs to downsize the RT department, the people he or she is most likely to keep are those with good soft skills.  Likewise, he's also more likely to consider those with soft skills for advanced assignments that might make you management material.

So anyone can learn hard skills to get you the job, yet learning the soft skills needed to keep your job is something only YOU can work on.  

References:

1. SearchCIO.com
2. Jobs.AOL.com

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The argument against serial ABGs, or, Cheerios cereal is better than serial ABGs

Why do doctors order serial ABGs anyway?  It's not like he could possibly know the patient is going to be in respiratory or metabolic distress every morning?  Wouldn't Alpha Bits be a better option for the patient?  Or how about Spaghetti O's?  Better yet, Fruity Pebbles or Fruit Loop Cereals would be much more enjoyable by the patient and therefore useful.  Yet simply ordering serial ABGs isn't of much use to the patient nor the doctor unless by luck of some crap shoot they so happen to be out of whack.  Yet one would hope that if the AM ABG two days from the time they were ordered are out of whack that the doctor would have picked up on it long before that time.  So that's why I'm proposing that Corn Flakes or even Cheerios would be a better option.  At least the patient would benefit from the added nutrients. How about Oat Meal?  At least Oat meal is proven to lower cholesterol.  Now, we won't get into the fact Oat meal doesn't even have any cholesterol in it to begin with, yet Oat meal would be much more beneficial to everyone involved than Serial ABGS.  So what's up with serial ABGs anyway?  Why the doctor fascination with them?  Why not just use the free and painless pulse oximetry or end tidal CO2 monitoring?  What do you think?

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To purge charts or not to purge charts?

By law a hospital or doctor's office only has to keep your medical records for seven years.  After seven years, it is up to the institution what they want to do with your records.  Some purge (delete or toss out) them, and others keep them forever.

National Jewish Health in Denver Colorado keeps records on file for 25 years, at which time they condense the chart.  My records for my six month stay there in 1985 would probably have come to thousands of pages, yet when I sent for them a few years ago I only got 25 pages. 

Personally, I think there should be some type of system whereby a person's medical records are stored in one location online and, with that person's permission, a hospital or doctor will have easy access to that information.  Although I understand why many would have reservations about this.

I think this would be nice, because there were medicines I had allergic reactions to when I was a kid that I have no idea what they are now.  I've also had tests to diagnose me with certain things, and there is no evidence of any of it. Last summer I needed to have surgery on my eye for the fourth time, and there was no record of my previous eye surgeries.  The doctor had to wing it.

Most medical records are burned or shredded, and all knowledge this way is lost.  This, I think, is not good.  The current system is not good, unless you have something to hide.

What do you think?

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If the stupid read this blog, they don't stay stupid long.

Stupid people don't read my blog.  I'm sure stupid people click on my blog from time to time, but stand assured it's only because a search accidentally lead them here.  If the stupid read this blog, they don't stay stupid long. They either leave or they become smart.  The entire premise of this blog is to make all of us smarter, and if stupid people come here they will become smart by default.  

I'm not trying to sound arrogant and condescending here, I'm just stating a fact.  Nothing on this blog is written based upon feelings and emotions.  Nothing on this blog is written based on a myth, unless it's a facetious version of it. What we do on this blog is show absurdity by being absurd, and we simplify the complex; we make things easy to understand.  We analyze and articulate ideas and scientific data.  So if the stupid find their way to this blog, and they somehow stick around for a while, there's no way they could leave stupid -- at least when it comes to respiratory therapy wisdom.

I must tell you that the stupid are among the intended audience of this blog, yet I highly doubt the stupid will be reading anything I write here.  It's simply a fact the stupid don't read.  It's because they don't read that they don't learn, and hence they stay stupid.  And let me state here that while I might disagree with some of what the medical profession believes in -- like the hypoxic drive hoax and hoaxonex -- doctors are not stupid.  The stupid are among my intended audience, yet so to are doctors and nurses and fellow respiratory therapists, none of which are stupid.  You cannot go to college and come out with a degree and be stupid.  You can be wrong -- hence the hypoxic drive hoax -- but you cannot be stupid.  So doctors and nurses and respiratory therapists are not stupid.  You cannot get a degree and remain stupid.  
And don't worry, the stupid aren't smart enough to know I'm writing about them. There's no scientific data on this, but the stupid don't even know they are stupid.  If they are smart enough to know that, then they aren't really stupid.  I say that because no stupid person will take the time to read my blog.  Stupid people choose not to be smart, perhaps because they don't know they are stupid.  The stupid might by chance hear something I write about from their friends or acquaintances, but then the question is whether they will be smart enough to know I'm talking about them, or trying to target them.  If I'm trying to target the stupid, and only the stupid, my audience won't be very big, and I would basically be writing to myself.  Such an attempt would be frivolous at best.

By chance I will have some stupid people coming to my blog.  I say this because I highly doubt the stupid really know they are stupid.  And I'm certainly not going to tell them, and neither will you.  It's called human decency.  We don't tell people the truth even when we know it, because then we would be judging. Then we would be mean, arrogant and condescending.  Plus who's to say we aren't stupid ourselves.  We aren't stupid as stupid is defined, but I'm sure every one of us has stupid tendencies. 

What I'm saying is we all have our weaknesses.  The mechanic might be smart when it comes to fixing cars, but that same person may not have a clue how to romanticise.  When it comes to keeping a relationship he may be stupid.  But that doesn't mean he's stupid. And that certainly doesn't mean we are going to tell him he's stupid when it comes to relationships, because that would make him mad, and we as a society don't want to offend people.  That job should be reserved for his good friend, or his wife or girlfriend.  It's her job to question his stupidity when it comes to relationships.  It's her job to challenge him and make him better, or even a little better.  And I suppose, in a way, that's kind of what I do on this blog.  No, I don't tell the truth about relationships, I tell the truth about respiratory therapy.

In the same way you may have the smartest doctor -- the best doctor in the world -- who still doesn't oxygenate COPD patients because he believes in the hypoxic drivec hoax.  The urologist may be the best urologist for 1000 miles, but still be stupid about oxygenating COPD patients.  He may be the best surgeon, but still be stupid about respiratory therapy.  The surgeon may be the best surgeon, but be stupid about bedside manners.  The Internist who takes care of you and your grandma may be the best Internist in the world, yet still be stupid about respiratory therapy. 

In fact, as noted in the 1982 version of Egan, the respiratory therapy profession was created because respiratory therapy was proven to be beyond the scope of nurses and doctors.  Our profession was created to fill that gap.  So in RT school that's what we are taught, and then the medical profession is so stupid, so blind to that fact, or at least not wanting to admit it, that they ignore our profession.  They continue to see us as ancillary staff or technicians. 

And no one will say anything to them for fear of offending them, for fear of ruining the doctor RT relationship, or out of respect for the medical profession.  We don't want to say anything because we are kind human beings.  We might be good friends with that doctor and don't want to hurt the relationship.  We might be simply coworkers with that doctor and nothing more.  We might simply respect that doctor.  Surely that doctor is smart or he wouldn't be a doctor. 

And it's for that reason, that kindness of the human spirit we RTs present with, whereby we don't want to be the one to tell them the truth, as Egan did in that 1982 book.  We're afraid to tell them that a continuous breathing treatment will not treat heart failure, or pulmonary fulmonating edema, or BiPAP does not force fluid out of the lungs (it helps, but that's not the reason), and the hypoxic drive theory is a hoax that merely works to force hypoxic patients to needlessly suffer.  We don't say these things because we are smart, and they are smart, and we respect that.  

Yet as the girlfriend of the mechanic who is terrible in relationships, it's the job of the best friend of that man to tell him or her the truth:  is it not?  I would contend that this job should fall on the RT bosses and administrators.  Yet they don't want to do anything for fear of hurting the relationship, and that's the same reason the girlfriend of the mechanic probably won't say anything to the mechanic either.  We don't want to challenge someones intelligence. We don't want to challenge someones ego.  As we all know, we all have egos. 

Even if you don't admit it, you have an ego.  It's a proven fact that every conflict between two people is because one or the other challenged the ego of the other person.  If the wife challenges the ego of the mechanic, he will be offended.  If I challenge -- if we RTs challenge -- stupid doctor orders we will be challenging the ego of that doctor. We will be risking making a doctor mad, and then we will risk our bosses coming down on us, and we will be risking losing our jobs. 

If I say to a nurse:  "that patient doesn't need a breathing treatment, he's wet," she will say, "You're being lazy and trying to get out of work."  The truth hurts.  It may hurt the person whose ego your hurting, and it will hurt you because you may be punished for stating the hurtful truth. 

By stating the truth we may be eating the hands that feed us.  When a doctor or nurse is mad, they write variances.  They will tell your boss you have a bad attitude.  You will risk being reprimanded or even fired.  And that, my friends, is why we don't see improvements in the medical profession. That's why the field of RT continues to stay in the dark ages.  That's why 80 percent of what we do is either a waste of time or delays time.  We are afraid to tell doctors the truth for fear of bursting their egos.  

It's because of this that stupid doctor orders are written.  It's because of this that we RTs are still treated as ancillary staff, even thought the NBRC has seen to it that we are the respiratory therapy experts, educated to the highest degree.  We are trained to fill the gap of a physician's respiratory therapy ignorance.  Yet despite that fact, we are still treated as ancillary staff, or as technicians.  They see us, many of them anyway, as just another person doing a task.  

I actually had a doctor tell me that once.  She basically pulled me aside and said:  "You are ancillary staff.  You are a tech.  You aren't to question my orders, and you aren't to interpret EKGs and you aren't to do critical thinking.  I order and you do."  She was the best ER doctor that we had, yet when it came to respiratory therapy she was ignorant.  Yet she fails to admit it.  I know I shouldn't say it, and I never would to her face, but she is stupid when it comes to respiratory therapy, as many doctors are.  And I'm sure they don't read my blog because people that are stupid about respiratory therapy don't want to come here. They don't want to read the truth. They don't want to have their egos offended.

It's the same reason that  most liberals don't want to read National Review, or why most conservatives don't want to watch MSNBC.  People don't want to hear that of which is contrary to what they were taught, even if what they were taught is completely wrong.  They will avoid hearing contrary thought like the plague.  They don't want to learn the truth because it would challenge their egos.  It would challenge what they learned in medical school back in 1982.  There's this old saying that the truth hurts and then it makes you better.

Yet since most people don't want to be hurt, they don't choose to read things that will hurt them; that will make them better.  If they do read things that hurt them, if they read the truth -- which is what my blog is all about -- they will become smarter.  And that's the premise of this blog post:  If the stupid read this blog, they don't stay stupid long. They either leave or they become smart.

Further reading:

A world of bronchodilator lies

A history of the hypoxic drive hoax

The RT/Doctor relationship
How to define smart
How intelligent are you?
13 myths of respiratory therapy

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