Monday, August 31, 2015
The phlegmatic asthmatic
There was an asthma kit I received when I was 14 with a game a comic book and an asthma game that taught you how to deal with an asthma attack. One of the things it mentioned was the wet noodle technique to help you relax. You just basically pretend you are a wet noodle and go limp. It was actually a nice way of teaching kids to work on relaxation techniques, or to be more like a peaceful phlegmatic asthmatic. Thus was the topic of comic strip #6. You may also read the accompanying post: "The Phlegmatic Asthmatic."
John Bottrell has had asthma so long that it has become a normal part of his life. As a child, he used the "wet noodle" technique to keep calm during an asthma attack. It works, but he's learned that asthma management is even better. Illustrated by Dash Shaw. (Originally published at healthcentral.com/asthma)
Sunday, August 30, 2015
'Olins: Part 3
The following is a continuation of our list of various types and forms of racemic and actual ventolin-tyes (o'lins) that we doctors keep esoteric from respiratory therapists so they continue to have procedures to justify their existence. Oh, and the treatments actually do help for the various disorders listed below. Seriously, we are not making this up.
235. Medicine: Historolin
Diagnosis: Asthma
Frequency: Q4-6
Effect: It is proven that keeping beta 2 receptors saturated with ventolin particles will keep asthma in remission. Such therapy may be deemed profligate in the out of hospital setting.
236. Medicine: Abdomnolin
Diagnosis: Had surgery on belly
Frequency: QID
Effect: Only works when prescribed by surgeon to prevent atelectasis and pneumonia caused by the surgeon. Warning to physician: side effect to second hand ventolin types is respiratory therapy apathy and grumpiness, so stay out of their way. Still order it, though, we're just saying; they are lazy and will try to convince you it's pointless, but we know it is not pointless. Yes, a study of 100 post op patients showed that, of 100 post op patients who were treated with QID ventolin, they all eventually got better. So we know some form of ventolin must be ordered. Note: not ordering Abdominoilin for post operative patients was not shown to decrease length of stay. Side effect to patient may be increased desire to go home, agitation, and possible irritation with the therapist who continues to wake them up for breathing treatments when they already know they can breathe just fine.
237. Medicine: Desatolin
Diagnosis: Aspiration Pneumonia
Frequency: QID
Effect: Once inhaled the ventolin particles join with a chemical called humidolin acetate to form H2O molecules. As these accumulate over the course of many days the patient will become filled with increased fluid so that oxygen molecules can float to the surface of the lungs so they can be exhaled. May be tried with regular or faux pneumonia, although studies show that it works best for pneumonia that was caused by reflux of stomach contents. Helicobacter pylori (H. pylori), a common bacteria found in the intestinal tract, might actually plunge out of the water and be exhaled during the exhalation phase due to helicopter-like rotors that have previously eluded the vision of scientists but may be seen when the bacteria is attached to ventolin-like substances in the air. It's a site worth seeing when hundreds, thousands, millions, even billions of H. Pylori escape their human captors in search of life on Mars. The good news is they die within seconds of exhalation.
238. Medicine: HEALButerol®
Diagnosis: Bone fractures
Frequency: QID
Effect: Rather than just giving albuterol to open up the air passages that are already open, this provides Orthopedic physicians a medicinal supplement proven to diffuse into the bloodstream once inhaled and seeps into bone material to cause fractured areas to rejoin and heal faster. The exact methodology is unknown, but a study showed that of 100 post op patients given HEALButerol® all eventually got better. So this was indication enough to confirm that the medicine magically heals bones as well as opens up airways, even if the airways are already open. You may also wish to try Knitolin.
Medicine: Knitolin
239. Diagnosis: Bone Fractures, especially fractured ribs
Frequency: QID
Effect: It knits bones so they heal better and the patient breathes better at the same time. If neither of those work, try tryagainolin. It works best when given in tandem with an incentive spirometer (IS)and acapella. Increased turbulence created by inhaling a deep breath with the IS pushes the knitolin particles deeper into the bone (sort of like hammer nail, so to speak) thus making the medicine particles work like a filling in a tooth to further supplement healing. The acepella helps to loosen and free any bacterial particles that might collect inside the fractured portions of the bone and inhibit healing and/ or cause an infection.
240. Medicine. Trainwreck-uterol
Diagnosis: Many, or Trainwreckeeeeism caused by the trainwreck virus that causes many of the organs of the body to become confused and not work right. Trainwreck-ism is a another disorder caused by the trainwreck virus that causes nurses and respiratory therapists to make poor decisions that wreck things and people. Trainwreckeeeism should not be confused with Trainwreck-ism. Because trainwreckeeeism has a lot of e's in it, it can be treated the same way a wheeze is: with an 'olin, particularly Trainwreck-uterol. Trainwreck-ism has no known treatment, and therefore you must not be anywhere withing 100 miles of such patients. Usually they are not hired. If they are, you should fire them immediately, because the disease is highly contagious.
Frequency: Q4ever
Effect. It has no effect on the disease processes, although it does attack to faux B2 receptors in throat muscles in and attempt to eeeeee-liminate the wheeze by soothing throat muscles (throatodilation) in order to make nurses and doctors happier.
241. Medicine. Fusolin
Diagnosis: Rib fracture
Frequency: QID
Effect: Increases tidal volume to prevent pneumonia and atelectasis. Works similar to the way IPPB used to overinflate good alveoli. May be alternated with Knitolin, HEALButerol®, preventolin, postopulterol and tryagainolin. May also try sputumolin to induce a cough. Avoid using ventolin for its cough suppressant qualities, as this defeats the purpose.
242. Medicine: Lupisolin (aka Aligatoruterol, Sharkuterol)
Diagnosis: Lupis
Frequency: At least QID
Effect: Ventolin particles go into the lungs and join with neutrophils to turn the ventolin particles into little critters that look like very sharp toothed alligators or sharks that kill and digest bacteria and viruses and other potentially harmful invaders so the immune system doesn't have to. I guess you can say that the ventolin particles formed look and act sort of like Pac Man and Mrs. Pacman. This works to suppress the immune system and to prevent inflammation caused by the disease, particularly in the heart, lungs, and brain (well, mostly in the lungs).
243. Medicine: Flapolin
Diagnosis: Loose or damaged Mitral valve
Frequency: Once
Effect: Mitral valve may be heard flapping, meaning that the valve is leaky. This form of ventolin causes an infusion of hardened, crystallized substances that are attracted only to the mitral valve to fortify it and assure the patient's safety until the valve can be replaced.
243. Medicine: Vasodilatolin
Diagnosis: Hypertension
Frequency: Q4-6
Effect: Dilates vessels to decrease blood pressure. Will require frequent inhalations to assure a high enough dose of the medicine is in the bloodstream at all times. So this is why we recommend it be given Q4-6 rather than just QID. A bonus is the patient will have to be awakened at least once, and this might make the patient mad and raise blood pressure that way. It works the same as BiPAP, which has a benefit of increasing blood pressure. May also place patient on BiPAP. The more uncomfortable the settings the better the effect. Please, do not admit this to respiratory therapists. Oh, you did already: Doh!
244. Medicine: BiPAP-uterol DS
Diagnosis: CO2 greater than 42 (boy, that's way too high, need to get it back down to normal)
Frequency: QID, Q6, Q4, or just make something up
Effect: Lubricates and soothes the vocal cords so you don't hear an audible wheeze (rhonchi, stridor). Works best if tried before BiPAP is ordered. If doesn't work, order BiPAP. Works well after BiPAP order too. If you continue to hear lots of noises in the lungs (especially if they annoy you), you probably should order BiPAP. IN this case, the medicine mayu have a bonus of lubricating the lips and cheeks so you don't hear the BLLLLPPPPPLLLLLTTTTTTTHHHHHHHH due to the fact the seal is not tight enough. It makes it so nurses don't keep calling respiratory because they don't feel like playing with the Velcro. May alternate with BiPAPuterol (to ward off evil spirits so you don't have to eventually ventilate this patient). Note: For patients with a big scruffy beard, a double dose may be beneficial. Or, just get off your ass and tighten the mask might work just as well. Or, if you're really brave, shave the beard)
245. Medicine: Normal Saline
Diagnosis. Asthma, COPD
Frequency: Q4
Effect: Draws salt out of epithelial cells and Type-II alveolar cells in order to treat bronchospasm due to dehydration.
246. Medicine: Retrospectuterol
Diagnosis. COPD, asthma, heart failure, pulmonary edema, kidney failure, lung cancer, etc.
Frequency: Q4-6
Effect: The patient was short of breath greater than 24 hours ago, therefore albuterol is indicated today. The patient may have been short of breath yesterday, or may have experienced asthma symptoms (at the age of 6) 25 years ago. Regardless, the retrospective qualities of albuterol-like particles have the ability to travel over the wrinkle in time scrub lungs clear of all past difficulties.
247. Medicine. Keepmeinolin
Diagnosis. Respiratory failure, hypoxia, pneunonia, heart failure, dyspnea (all of which requires oxygen and IV medications to keep the patient alive)
Frequency. Q once
Effect. Works similar to exercise in that it stimulates the brain to release a chemical called endorphins. They act like analgesics such as morphine to diminish the perception of pain, cause a sedative effect, reduce stress, ward off anxiety, ward off depression, boost self esteem, and improve sleep. It causes a sense of euphoria similar to that produced from morphine with out the risk of addiction. Generally, the effect only lasts until the mist in the room clears, so it's usually only prescribed one time, as a last ditch effort, when a patient threatens to leave against medical advice (AMA). The medicine should calm the patient down just enough to convince her that she really does need to be in the hospital.
247. Medicine. Transmitolin, Accousticsolin
Diagnosis. CHF, Heart Failure, ETOH, Dehydration, old age
Frequency. QID
Effect. Prevents upper airway rhonchi from transmitting to other lung fields to prevent specious documenting of wheezes. It's a medicine that was concocted in the laboratory of Dr. Ven Tolin and his assistant, Paul RiTT, with the intent to discourage physicians from ordering breathing treatments due to upper airway noises confused for wheezing. The medical community generally has an aversion to this medicine, and so it has rarely been used to this point. A Congressional Committee actually discussed this, and it almost made it into the Affordable Care Act in order to cut government spending, only to be cut from the bill at the last moment when it was discovered the individual hospitals have to absorb the costs of wasteful breathing treatments, and not Uncle Sam.
248. Medicine. Keepmeawakeolin
Diagnosis. COPD, Sleep Apnea
Frequency. Q4 ATC
Effect. To a nerve cell, Keepmeawakeolin looks like a coffee molecule which looks like adenosine. It then is allowed to attach to adenosine receptors, thus preventing adenosine from attaching to them. So instead of adenosine slowing you down so you can sleep, Keepmeawakeolin keeps you awake. Adenosine dilates blood vessels in the brain, presumably to keep your brain well oxygenated while you are sleeping and your breathing is more relaxed. Keepmealiveolin mimics this effect, thus causing vasodilation of the vessels in the brain to assure adequate oxygenation while you are not sleeping. A side effect of this is that it may cause a headache, which is where caffeine comes in handy. About three hours after dosing, keepmealiveolin starts to dissolve, opening up just enough adenosine receptors for caffeine to attach. This should be enough, however, to constrict brain vessels, thus ridding you of your headache. Still, once the rest of the keepmealiveoline molecules dissipate, the next dose should be due. A morning dose of coffee is highly recommended, although it should be given about an hour prior to the treatment is due.
A side effect is insomnia that lasts for the duration of this type of treatment. It is typically not recommended to continue this treatment after discharge to home, as it often results in the viscous and never ending cycle of taking keepmealiveolin to improve oxygenation while you are sleeping and drinking coffee to offset the side effect of headache in the morning. Another side effect is refractory headache, which is a headache caused by the medicine to begin with. After doing all this reading (if you are still with me), the brain usually forgets about the bronchodilating effect. Another idea is to only give the medicine at night, and allow the patient to refuse therapy while awake. Still, because respiratory therapists hate waking people up, an ideal order for this is Q4 ATC (Around The Clock). This lets the RT know you mean business.
249. Medicine. Alcurital (See Ad Here)
Effect. This is the only medicine clinically not proven but believed to by nurses and... doctors (yes, doctors) to cure all that ails you And best of all It works even when You have clear lungsounds Hence the name: Alcurital.
Side Effects: Alcurital.for clear lungsounds. Side effects include anxiety, nervousness, headache, increased heart rate, death if consume more than 55 miligrams in a day, boredom, pissy RTs. However, studies show the medicine cures all ailments, but it has no effect on stupidity. Do not use if you have a wise physician or nurse. Not expected to result in increased brain cells. Not expected to prevent accidents. While it can be used prophylactically, it will not prevent all ailments. Don't worry, as no studies were done to come to any of these conclusions, it's simply based on feel good: it looks good, sounds good, feels good, then it is a fact. One study of 100 post op patients given Alcurital eventually recovered, so now it only makes sense that it
works.
250. Medicine. Mucinexolinuterol
Diagnosis. COPD, pneumonia, Cystic Fibrosis
Symptom. Thick secretions; difficult expectoration
Efficacy. The fact that the suffix olin and the suffix uterol are in the name means it has 10 times the ability to loosen thick secretions as Mucinex and albuterol alone.
251. Medicine. Diverticulobuterol
Diagnosis. Diverticulosis
Frequency. QID
Effect. Bronchodilators have been shown to attach to fake beta receptors in the colon to relax smooth muscles that wrap around the intestines to help release trapped particles. Similar to pneumonia, the medicine also magically reduces inflammation and smelling to ease pain and suffering caused by diverticulitis.
Further reading:
235. Medicine: Historolin
Diagnosis: Asthma
Frequency: Q4-6
Effect: It is proven that keeping beta 2 receptors saturated with ventolin particles will keep asthma in remission. Such therapy may be deemed profligate in the out of hospital setting.
236. Medicine: Abdomnolin
Diagnosis: Had surgery on belly
Frequency: QID
Effect: Only works when prescribed by surgeon to prevent atelectasis and pneumonia caused by the surgeon. Warning to physician: side effect to second hand ventolin types is respiratory therapy apathy and grumpiness, so stay out of their way. Still order it, though, we're just saying; they are lazy and will try to convince you it's pointless, but we know it is not pointless. Yes, a study of 100 post op patients showed that, of 100 post op patients who were treated with QID ventolin, they all eventually got better. So we know some form of ventolin must be ordered. Note: not ordering Abdominoilin for post operative patients was not shown to decrease length of stay. Side effect to patient may be increased desire to go home, agitation, and possible irritation with the therapist who continues to wake them up for breathing treatments when they already know they can breathe just fine.
237. Medicine: Desatolin
Diagnosis: Aspiration Pneumonia
Frequency: QID
Effect: Once inhaled the ventolin particles join with a chemical called humidolin acetate to form H2O molecules. As these accumulate over the course of many days the patient will become filled with increased fluid so that oxygen molecules can float to the surface of the lungs so they can be exhaled. May be tried with regular or faux pneumonia, although studies show that it works best for pneumonia that was caused by reflux of stomach contents. Helicobacter pylori (H. pylori), a common bacteria found in the intestinal tract, might actually plunge out of the water and be exhaled during the exhalation phase due to helicopter-like rotors that have previously eluded the vision of scientists but may be seen when the bacteria is attached to ventolin-like substances in the air. It's a site worth seeing when hundreds, thousands, millions, even billions of H. Pylori escape their human captors in search of life on Mars. The good news is they die within seconds of exhalation.
238. Medicine: HEALButerol®
Diagnosis: Bone fractures
Frequency: QID
Effect: Rather than just giving albuterol to open up the air passages that are already open, this provides Orthopedic physicians a medicinal supplement proven to diffuse into the bloodstream once inhaled and seeps into bone material to cause fractured areas to rejoin and heal faster. The exact methodology is unknown, but a study showed that of 100 post op patients given HEALButerol® all eventually got better. So this was indication enough to confirm that the medicine magically heals bones as well as opens up airways, even if the airways are already open. You may also wish to try Knitolin.
Medicine: Knitolin
239. Diagnosis: Bone Fractures, especially fractured ribs
Frequency: QID
Effect: It knits bones so they heal better and the patient breathes better at the same time. If neither of those work, try tryagainolin. It works best when given in tandem with an incentive spirometer (IS)and acapella. Increased turbulence created by inhaling a deep breath with the IS pushes the knitolin particles deeper into the bone (sort of like hammer nail, so to speak) thus making the medicine particles work like a filling in a tooth to further supplement healing. The acepella helps to loosen and free any bacterial particles that might collect inside the fractured portions of the bone and inhibit healing and/ or cause an infection.
240. Medicine. Trainwreck-uterol
Diagnosis: Many, or Trainwreckeeeeism caused by the trainwreck virus that causes many of the organs of the body to become confused and not work right. Trainwreck-ism is a another disorder caused by the trainwreck virus that causes nurses and respiratory therapists to make poor decisions that wreck things and people. Trainwreckeeeism should not be confused with Trainwreck-ism. Because trainwreckeeeism has a lot of e's in it, it can be treated the same way a wheeze is: with an 'olin, particularly Trainwreck-uterol. Trainwreck-ism has no known treatment, and therefore you must not be anywhere withing 100 miles of such patients. Usually they are not hired. If they are, you should fire them immediately, because the disease is highly contagious.
Frequency: Q4ever
Effect. It has no effect on the disease processes, although it does attack to faux B2 receptors in throat muscles in and attempt to eeeeee-liminate the wheeze by soothing throat muscles (throatodilation) in order to make nurses and doctors happier.
241. Medicine. Fusolin
Diagnosis: Rib fracture
Frequency: QID
Effect: Increases tidal volume to prevent pneumonia and atelectasis. Works similar to the way IPPB used to overinflate good alveoli. May be alternated with Knitolin, HEALButerol®, preventolin, postopulterol and tryagainolin. May also try sputumolin to induce a cough. Avoid using ventolin for its cough suppressant qualities, as this defeats the purpose.
242. Medicine: Lupisolin (aka Aligatoruterol, Sharkuterol)
Diagnosis: Lupis
Frequency: At least QID
Effect: Ventolin particles go into the lungs and join with neutrophils to turn the ventolin particles into little critters that look like very sharp toothed alligators or sharks that kill and digest bacteria and viruses and other potentially harmful invaders so the immune system doesn't have to. I guess you can say that the ventolin particles formed look and act sort of like Pac Man and Mrs. Pacman. This works to suppress the immune system and to prevent inflammation caused by the disease, particularly in the heart, lungs, and brain (well, mostly in the lungs).
243. Medicine: Flapolin
Diagnosis: Loose or damaged Mitral valve
Frequency: Once
Effect: Mitral valve may be heard flapping, meaning that the valve is leaky. This form of ventolin causes an infusion of hardened, crystallized substances that are attracted only to the mitral valve to fortify it and assure the patient's safety until the valve can be replaced.
243. Medicine: Vasodilatolin
Diagnosis: Hypertension
Frequency: Q4-6
Effect: Dilates vessels to decrease blood pressure. Will require frequent inhalations to assure a high enough dose of the medicine is in the bloodstream at all times. So this is why we recommend it be given Q4-6 rather than just QID. A bonus is the patient will have to be awakened at least once, and this might make the patient mad and raise blood pressure that way. It works the same as BiPAP, which has a benefit of increasing blood pressure. May also place patient on BiPAP. The more uncomfortable the settings the better the effect. Please, do not admit this to respiratory therapists. Oh, you did already: Doh!
244. Medicine: BiPAP-uterol DS
Diagnosis: CO2 greater than 42 (boy, that's way too high, need to get it back down to normal)
Frequency: QID, Q6, Q4, or just make something up
Effect: Lubricates and soothes the vocal cords so you don't hear an audible wheeze (rhonchi, stridor). Works best if tried before BiPAP is ordered. If doesn't work, order BiPAP. Works well after BiPAP order too. If you continue to hear lots of noises in the lungs (especially if they annoy you), you probably should order BiPAP. IN this case, the medicine mayu have a bonus of lubricating the lips and cheeks so you don't hear the BLLLLPPPPPLLLLLTTTTTTTHHHHHHHH due to the fact the seal is not tight enough. It makes it so nurses don't keep calling respiratory because they don't feel like playing with the Velcro. May alternate with BiPAPuterol (to ward off evil spirits so you don't have to eventually ventilate this patient). Note: For patients with a big scruffy beard, a double dose may be beneficial. Or, just get off your ass and tighten the mask might work just as well. Or, if you're really brave, shave the beard)
245. Medicine: Normal Saline
Diagnosis. Asthma, COPD
Frequency: Q4
Effect: Draws salt out of epithelial cells and Type-II alveolar cells in order to treat bronchospasm due to dehydration.
246. Medicine: Retrospectuterol
Diagnosis. COPD, asthma, heart failure, pulmonary edema, kidney failure, lung cancer, etc.
Frequency: Q4-6
Effect: The patient was short of breath greater than 24 hours ago, therefore albuterol is indicated today. The patient may have been short of breath yesterday, or may have experienced asthma symptoms (at the age of 6) 25 years ago. Regardless, the retrospective qualities of albuterol-like particles have the ability to travel over the wrinkle in time scrub lungs clear of all past difficulties.
247. Medicine. Keepmeinolin
Diagnosis. Respiratory failure, hypoxia, pneunonia, heart failure, dyspnea (all of which requires oxygen and IV medications to keep the patient alive)
Frequency. Q once
Effect. Works similar to exercise in that it stimulates the brain to release a chemical called endorphins. They act like analgesics such as morphine to diminish the perception of pain, cause a sedative effect, reduce stress, ward off anxiety, ward off depression, boost self esteem, and improve sleep. It causes a sense of euphoria similar to that produced from morphine with out the risk of addiction. Generally, the effect only lasts until the mist in the room clears, so it's usually only prescribed one time, as a last ditch effort, when a patient threatens to leave against medical advice (AMA). The medicine should calm the patient down just enough to convince her that she really does need to be in the hospital.
247. Medicine. Transmitolin, Accousticsolin
Diagnosis. CHF, Heart Failure, ETOH, Dehydration, old age
Frequency. QID
Effect. Prevents upper airway rhonchi from transmitting to other lung fields to prevent specious documenting of wheezes. It's a medicine that was concocted in the laboratory of Dr. Ven Tolin and his assistant, Paul RiTT, with the intent to discourage physicians from ordering breathing treatments due to upper airway noises confused for wheezing. The medical community generally has an aversion to this medicine, and so it has rarely been used to this point. A Congressional Committee actually discussed this, and it almost made it into the Affordable Care Act in order to cut government spending, only to be cut from the bill at the last moment when it was discovered the individual hospitals have to absorb the costs of wasteful breathing treatments, and not Uncle Sam.
248. Medicine. Keepmeawakeolin
Diagnosis. COPD, Sleep Apnea
Frequency. Q4 ATC
Effect. To a nerve cell, Keepmeawakeolin looks like a coffee molecule which looks like adenosine. It then is allowed to attach to adenosine receptors, thus preventing adenosine from attaching to them. So instead of adenosine slowing you down so you can sleep, Keepmeawakeolin keeps you awake. Adenosine dilates blood vessels in the brain, presumably to keep your brain well oxygenated while you are sleeping and your breathing is more relaxed. Keepmealiveolin mimics this effect, thus causing vasodilation of the vessels in the brain to assure adequate oxygenation while you are not sleeping. A side effect of this is that it may cause a headache, which is where caffeine comes in handy. About three hours after dosing, keepmealiveolin starts to dissolve, opening up just enough adenosine receptors for caffeine to attach. This should be enough, however, to constrict brain vessels, thus ridding you of your headache. Still, once the rest of the keepmealiveoline molecules dissipate, the next dose should be due. A morning dose of coffee is highly recommended, although it should be given about an hour prior to the treatment is due.
A side effect is insomnia that lasts for the duration of this type of treatment. It is typically not recommended to continue this treatment after discharge to home, as it often results in the viscous and never ending cycle of taking keepmealiveolin to improve oxygenation while you are sleeping and drinking coffee to offset the side effect of headache in the morning. Another side effect is refractory headache, which is a headache caused by the medicine to begin with. After doing all this reading (if you are still with me), the brain usually forgets about the bronchodilating effect. Another idea is to only give the medicine at night, and allow the patient to refuse therapy while awake. Still, because respiratory therapists hate waking people up, an ideal order for this is Q4 ATC (Around The Clock). This lets the RT know you mean business.
249. Medicine. Alcurital (See Ad Here)
Effect. This is the only medicine clinically not proven but believed to by nurses and... doctors (yes, doctors) to cure all that ails you And best of all It works even when You have clear lungsounds Hence the name: Alcurital.
Side Effects: Alcurital.for clear lungsounds. Side effects include anxiety, nervousness, headache, increased heart rate, death if consume more than 55 miligrams in a day, boredom, pissy RTs. However, studies show the medicine cures all ailments, but it has no effect on stupidity. Do not use if you have a wise physician or nurse. Not expected to result in increased brain cells. Not expected to prevent accidents. While it can be used prophylactically, it will not prevent all ailments. Don't worry, as no studies were done to come to any of these conclusions, it's simply based on feel good: it looks good, sounds good, feels good, then it is a fact. One study of 100 post op patients given Alcurital eventually recovered, so now it only makes sense that it
works.
250. Medicine. Mucinexolinuterol
Diagnosis. COPD, pneumonia, Cystic Fibrosis
Symptom. Thick secretions; difficult expectoration
Efficacy. The fact that the suffix olin and the suffix uterol are in the name means it has 10 times the ability to loosen thick secretions as Mucinex and albuterol alone.
251. Medicine. Diverticulobuterol
Diagnosis. Diverticulosis
Frequency. QID
Effect. Bronchodilators have been shown to attach to fake beta receptors in the colon to relax smooth muscles that wrap around the intestines to help release trapped particles. Similar to pneumonia, the medicine also magically reduces inflammation and smelling to ease pain and suffering caused by diverticulitis.
Further reading:
Saturday, August 29, 2015
Albuterol leading treatment for random dyspnea
While it has always been assumed, the Real Physician's Creed Association has now officially declared Albuterol a top line treatment for all dyspnea. "Treat as bronchospasm first and then differentiate. Never doubt that there is underlying bronchospasm," said RPCA chair Dr. Ven Tolin.
The decision was the result of a five minute panel discussion based on a complaint by RATS NEST president Mike Olin. "We are deeply disappointed in this decision," Olin said, "We figured they would have at least given equal time to considering FUROSESONEROLAQUINOX, the latest treatment for miscellaneous dyspnea.
Olin added, "I'm very frustrated. The medical profession has a long history of being resistant to change unless that change results in more needless work for respiratory therapists and nurses. This sort of adds credence to the saying, 'Why think when you can just order albuterol?'"
Dr. Muster of the Faux Society for the American Medical Association responded to Olin's comments by saying: "I think Olin is one of the brightest men in the medical profession. Still, all the studies in the world that show albuterol only cures bronchospasm simply don't make sense. The fact that ordering albuterol makes us feel we did something good is all the proof you need that all pulmonary disorders --and many other disorders too -- benefit from a dose of nebulized albuterol."
Tuesday, August 25, 2015
How to spot a bronchodilatoraholic
Bronchodilatoraholics often hide when puffing, as they do not want to seek attention or sympathy. While hardluck asthmatics may rely on their inhalers regardless that they are gallant asthmatics, it's still a good idea to know how to spot a bronchodilatoraholic, especially if the bronchodilatoraholic is a goofus asthmatic and is abusing the inhaler. You can read the accompanying article how to spot a bronchodilatoraholic. Otherwise, here is comic strip #5.
Do you sleep with your inhaler under your pillow? Do people call you "puffer head?" Do you have inhalers hidden all over your home? If you do, you just might be a bronchodilatoraholic. Here are 31 signs that you might be overusing your quick-relief asthma inhaler.
Monday, August 24, 2015
The Bronchodilatoraholic
I first heard the term bronchodilatoraholic from fellow asthmatic and friend, Stephen Gaudet. He mentioned it in one of his blog posts at breathinstephen.com. I think the general definition was initially intended to refer to asthmatics who rely heavily on bronchodilators. My publisher, on the other hand, defined it as asthmatics who abuse their inhalers.
John Bottrell had long overused (and sometimes abused) his quick-relief asthma inhalers, joining the ranks of asthmatics known as bronchodilatoraholics. Find out how he broke the habit. Illustrated by Dash Shaw. (Originally published at healthcentral.com/asthma.)
So this was my first disagreement I had with my publisher. I insisted that being dependent on, and abusing, are two different things. In the end, especially considering I was new to the business at the time, she won. The term bronchodilator became synonymous with depended on and abuser of inhalers.
Regardless, the term was one of 11 types of asthmatics. You can also read about my confession: Confessions of a recovering bronchodilatoraholic. You can also learn how to spot a bronchodilator, although you'll have to be vigilant, because often they surreptitiously puff. And if you do find yourself puffing frequently, you are not alone.
Saturday, August 22, 2015
Study: Secondhand albuterol linked with side effects
Researchers followed 1,600 newly graduated respiratory therapists over a period of ten years between July 7, 2002 and July 14, 2012. Six hundred sixty of the therapists gave an average of 10 albuterol breathing treatments in a given day. A control group of 720 therapists was given a placebo to give to their patients. But they were told to just sit in the RT Cave and watch movies on Netflix or play on their iPhones. Six hundred twenty therapists were disqualified for already having been diagnosed with respiratory therapy apathy syndrome (RATS).
The results showed that 100% of the therapists who gave albuterol breathing treatments developed the symptoms, with 75% experiencing increased incite within the first year doling out treatments (a minimum of 36 hour work week was required of all participants), and 82.5% developing a dry sense of humor within the first eight months.
Level of IQ was tested using a typical IQ scale, although adjusted for respiratory therapy wisdom. A typical question might entail, "Is heart failure treated with Ventolin?" Members of the control group were too bound to their fantasy world's to have time to answer the question. Members of the non-control group all answered the question correctly, with one scratching a comment in the margins of the test (taken on paper because because), "Are you kidding me! Of course not."
The study was the first ever study to study the study abilities of respiratory therapists and the possible impact that ventolin may have on their demeanor.
"It was just amazing the results that we discovered by doing this simple scientific study," said Dr. Carl Olin of Westbrook University where the study was conducted. "Who ever would have thought that people with only an associate's degree could actually know more about respiratory therapy than physicians?"
Cal Tripper, Medical Director of Respiratory Therapy at Buterol University, said, "It has been observed for years that respiratory therapists display a unique wisdom, particularly regarding respiratory therapy, although it was tough to put a finger on the reason before this study. I highly recommend to other physicians to talk to a respiratory therapist, ask them if they have an opinion or a recommendation, the next time a patient has respiratory complications. The truth to the matter is, even though they only have associate's degrees, they may actually know more than we do about how to manage respiratory therapy. And it's all because of second hand albuterol."
Friday, August 21, 2015
Clinical Trials Made Easy
In order to find out if albuterol actually makes asthmatics feel better, we have to have something to compare albuterol with. For this reason, we are going to create two groups:
- Experimental Group. When a medicine is tested, these are the individuals who actually get to take the medicine. If albuterol were being tested, these folks would actually get the medicine.
- Control Group. When a medicine is tested, these are the individuals who do not get to take the actual medicine. They take a placebo instead. This is needed so the examiners have something to compare the results with. If albuterol were being tested, these folks would just inhale normal saline.
- Tested Drug. Albuterol with 3 cc normal saline
- Comparator. Normal Saline
- Placebo. The comparator. A harmless or fake medicine.
- Null Hypothesis. To begin, experimenters will assume that both the tested drug and the comparator are equal, that there is no difference between the two. The study will then prove whether this is true, or whether the tested drug generates a benefit.
So now let us assume that all the people in the experimental group and all the patients in the control group have been diagnosed with moderate to severe asthma and have uncontrolled asthma. None of the patients have taken any asthma medicine within the previous 12 hours. Pulmonary function testing is done on all the patients, followed by a period of 20 minutes of rest. The experimental group is then given the tested drug (albuterol with 3cc of normal saline) and the control group is given the placebo (3cc normal saline). Both the tested drug and the placebo are inhaled over 10 minutes using a nebulizer.
All the patients now take another pulmonary function test. Obviously, many such studies were performed in the past showing that albuterol improves lung function while the placebo did not improve lung function. The null hypothesis is now proven wrong as albuterol is shown to improve lung function while normal saline alone does not.
Let us take another example here. Many respiratory therapists have said that a majority of patients who receive an albuterol breathing treatment say they feel better after the treatment. The hypothesis here is that a placebo will work just as well as albuterol in generating a perceived benefit. This hypothesis was tested recently on 39 mild to moderate asthmatics.
This calls for some more definitions.
- Perceived Response. This is when people who participate in the control group and received a placebo document that they feel better. Of course we know it's not possible because they did not even receive the medicine.
- Placebo Response (Placebo Effect). This is where a patient reports a perceived response from the placebo. They think they received albuterol so they think they feel better. The study showed that 50% of those in the placebo group reported a perceived response to the medicine.
As I wrote regarding this study before: "This is interesting to say the least. We know that albuterol really does make breathing easier in patients who are having actual bronchospasm. However, evidence also suggests that giving albuterol to anyone who is short of breath may produce the placebo response. So now you know why doctors treat all pulmonary diseases as asthma."
You also now know how clinical trials work. You also now understand how we must take the interpretations of clinical trials with a grain of salt, because they are not always accurate.
Further reading:
RT Cave on Twitter
Thursday, August 20, 2015
Meet Joe Goofus, the bad asthmatic
I really enjoyed writing about Joe Goofus, the asthmatic who does everything wrong. I really wanted to write more posts about him. He was the topic of comic strip #3. You can read the accompanying article about the bumbling asthmatic: "Meet Joe Goofus: The Asthmatic You Don't Want To Be (But Probably Are).
Asthmatics like our friend Joe don't like anything to interfere with their fun. They have an asthma attack, go to the ER, half-listen to the nurses, doctors and respiratory therapists, and then take their preventative medicine until they start to feel better. Then they go back to having fun, until the next asthma attack. Illustrated by Dash Shaw. (originally published at healthcentral.com/ asthma)
Asthmatics like our friend Joe don't like anything to interfere with their fun. They have an asthma attack, go to the ER, half-listen to the nurses, doctors and respiratory therapists, and then take their preventative medicine until they start to feel better. Then they go back to having fun, until the next asthma attack. Illustrated by Dash Shaw. (originally published at healthcentral.com/ asthma)
Wednesday, August 19, 2015
Study links premature birth to respiratory symptoms
A new study reported on at RT magazine suggests that deliveries at 37 or 38 weeks gestation are linked to an increased risk for respiratory symptoms in childhood. This might be evidence enough to encourage physicians to delay inductions and c-sections as long as possible.
As a matter of fact, the results were rather significant. It shows that children born prematurely had a 70 percent increased risk of having respiratory symptoms by the age of ten, and up to a 50 percent greater risk of needing to use rescue inhalers.
They also had an increased risk of respiratory infections and antibiotic use beginning at the age of five when compared to those children born closer to term (40 weeks).
This is more evidence how it is important for delivering physicians to keep in mind the best interest of the unborn child and not their own convenience, and potential profits, when delivering a child.
As a matter of fact, the results were rather significant. It shows that children born prematurely had a 70 percent increased risk of having respiratory symptoms by the age of ten, and up to a 50 percent greater risk of needing to use rescue inhalers.
They also had an increased risk of respiratory infections and antibiotic use beginning at the age of five when compared to those children born closer to term (40 weeks).
This is more evidence how it is important for delivering physicians to keep in mind the best interest of the unborn child and not their own convenience, and potential profits, when delivering a child.
Tuesday, August 18, 2015
Meet Jake Gallant, the perfect asthmatic
My second comic I wrote for healthcentral.com was about gallant asthmatics. I got the idea for Jake Gallant and his friend Joe Goofus from the "Goofus and Gallant" comic strip in the old "Highlights" children's magazine. I was going to feature a regular comic featuring the two prior to the budget being stripped after only seven comics were produced. Here is comic #2. You can read the accompanying article "The Gallant Asthmatic." You may notice, as I publish these comics, that it was from here that I designed my header.
Jake, and gallant asthmatics like him, are a doctor's best patients because they do everything exactly as they are directed. They have an asthma action plan. They have their bronchodilator with them at all times, but only use it when necessary. They religiously take their controller, anti-inflammatory medicines. Illustrated by Dash Shaw. (originally published at healthcentral.com/ asthma)
Jake, and gallant asthmatics like him, are a doctor's best patients because they do everything exactly as they are directed. They have an asthma action plan. They have their bronchodilator with them at all times, but only use it when necessary. They religiously take their controller, anti-inflammatory medicines. Illustrated by Dash Shaw. (originally published at healthcentral.com/ asthma)
Monday, August 17, 2015
I am your respiratory therapist
When I first started out as a writer for healthcentral.com I wrote asthma comics that were illustrated by the infamous Dash Shaw. It was quite the honor, and definitely the neatest project I ever participated in as a writer. The initial comic was just me introducing myself and my profession to the asthma community. You can view the original article: "I Am Your Respiratory Therapist."
John Bottrell is an asthma sufferer and respiratory therapist. He explains how he helps asthmatics breathe and how he learned to breath better too. Illustrations by Dash Shaw. (originally published at healthcentral.com/ asthma)
John Bottrell is an asthma sufferer and respiratory therapist. He explains how he helps asthmatics breathe and how he learned to breath better too. Illustrations by Dash Shaw. (originally published at healthcentral.com/ asthma)
Sunday, August 16, 2015
Wisdom of a Random Respiratory Therapist
I received an email from a respiratory therapist friend of mine who works for a hospital I will not name to protect my friend.
He said the patient had a shadow on the x-ray, and so the physician proudly said this was the reason for the breathing treatment.
He said another patient was diagnosed with end stage COPD, and the physician won't realize it's heart failure for a couple days.
He said an albuterol breathing treatment opened up one patient's airways so much it made the patient's airways wet.
He said that the reason Duoneb is usually ordered rather than just albuterol is not because a study showed ipatropium bromide given in tandem benefits patients, it's because someone with a bright idea decided that if one medicine works great another given with it must work better.
Seriously, this is how medical research works, folks.
He reminded us of the study done once on 100 post op patients. They were all given a bronchodilator QiD and were all eventually discharged. So for the next 30 years all post op patients were given a bronchodilator
Of course he also reminded us of the interns who were ordered to do all the ABGs they ordered: the number of ABG orders diminished by 50 percent.
He said he told the nurse's aid the patient was wet, and she proceeded to change the patient's diaper. To her defense, she was new. He said the aid was a good sport and even she had a good laugh about it.
He said that most of what we do as respiratory therapists we do just so the hospital can get reimbursed. How else do you explain orders for three albuterol breathing treatments when all that was needed was one or none.
This doesn't make sense unless you understand that CMS Regulation says patients with any lung disease are only sick enough to be admitted if they fail three albuterol breathing treatments.
He said it's not the fault of the hospital, nor the physician, that so many frivolous therapies are ordered, it's the result of politicians sitting in leather chairs in Washington D.C. who have too much time on their hands and think that doing something is better than doing nothing.
Just to give you an idea of the idiocy of the medical profession, consider that Hippocrates defined asthma as all dyspnea. Even while scientists have since extricated hundreds of diseases out from under the rubric term asthma, physicians still treat all dypsnea as asthma, and usually under the ruse: "Well, at least it can't hurt."
And yes, he said, a pulmonary diseases are also still treated as asthma. I even had a very credible doctor once go into a 10 minute long discussion with me on how she believed albuterol helped people in CHF. He said, "That ten minutes was a long time, because I had to somehow prevent myself from laughing."
He said that when posed with a problem, people who are making hospital regulations ask the question: "Does it make me feel good." Sure, it feels good to come up with A solution. Still, their solutions usually result in chaos. What they ought to ask themselves is: "Will it do any good?"
He said these same people who, when they see a minor problem, say things like: "We have to do something." A better saying would be: "It's better to do nothing than something stupid," or "It's better to do nothing than just something that makes us feel good."
Bottom line, he said, is, rather than create regulations because they make sense, they make regulations because it sounds like a good idea and makes them feel good about themselves. Yet the end result is usually chaos. Chaos for an RT is RT Apathy and Burnout.
He said we RTs do not complain because we don't want to work. We complain because too much of what we do is a waste of time or delays time.
Funny thing is, he said, I talk to many doctors who feel the same way. They get tired of ordering therapies just to make the family think we are doing something, or just to make sure the hospital gets reimbursed. Regulations create doctor apathy too. "Regulations cause chaos."
Oh, and one more thing. I had a doctor the other day say to me, "Why are you always insulting my patients. I said, "What do you mean?" He said, "Well, you are always saying they are 'dim and clear.'"
He said the patient had a shadow on the x-ray, and so the physician proudly said this was the reason for the breathing treatment.
He said another patient was diagnosed with end stage COPD, and the physician won't realize it's heart failure for a couple days.
He said an albuterol breathing treatment opened up one patient's airways so much it made the patient's airways wet.
He said that the reason Duoneb is usually ordered rather than just albuterol is not because a study showed ipatropium bromide given in tandem benefits patients, it's because someone with a bright idea decided that if one medicine works great another given with it must work better.
Seriously, this is how medical research works, folks.
He reminded us of the study done once on 100 post op patients. They were all given a bronchodilator QiD and were all eventually discharged. So for the next 30 years all post op patients were given a bronchodilator
Of course he also reminded us of the interns who were ordered to do all the ABGs they ordered: the number of ABG orders diminished by 50 percent.
He said he told the nurse's aid the patient was wet, and she proceeded to change the patient's diaper. To her defense, she was new. He said the aid was a good sport and even she had a good laugh about it.
He said that most of what we do as respiratory therapists we do just so the hospital can get reimbursed. How else do you explain orders for three albuterol breathing treatments when all that was needed was one or none.
This doesn't make sense unless you understand that CMS Regulation says patients with any lung disease are only sick enough to be admitted if they fail three albuterol breathing treatments.
He said it's not the fault of the hospital, nor the physician, that so many frivolous therapies are ordered, it's the result of politicians sitting in leather chairs in Washington D.C. who have too much time on their hands and think that doing something is better than doing nothing.
Just to give you an idea of the idiocy of the medical profession, consider that Hippocrates defined asthma as all dyspnea. Even while scientists have since extricated hundreds of diseases out from under the rubric term asthma, physicians still treat all dypsnea as asthma, and usually under the ruse: "Well, at least it can't hurt."
And yes, he said, a pulmonary diseases are also still treated as asthma. I even had a very credible doctor once go into a 10 minute long discussion with me on how she believed albuterol helped people in CHF. He said, "That ten minutes was a long time, because I had to somehow prevent myself from laughing."
He said that when posed with a problem, people who are making hospital regulations ask the question: "Does it make me feel good." Sure, it feels good to come up with A solution. Still, their solutions usually result in chaos. What they ought to ask themselves is: "Will it do any good?"
He said these same people who, when they see a minor problem, say things like: "We have to do something." A better saying would be: "It's better to do nothing than something stupid," or "It's better to do nothing than just something that makes us feel good."
Bottom line, he said, is, rather than create regulations because they make sense, they make regulations because it sounds like a good idea and makes them feel good about themselves. Yet the end result is usually chaos. Chaos for an RT is RT Apathy and Burnout.
He said we RTs do not complain because we don't want to work. We complain because too much of what we do is a waste of time or delays time.
Funny thing is, he said, I talk to many doctors who feel the same way. They get tired of ordering therapies just to make the family think we are doing something, or just to make sure the hospital gets reimbursed. Regulations create doctor apathy too. "Regulations cause chaos."
Oh, and one more thing. I had a doctor the other day say to me, "Why are you always insulting my patients. I said, "What do you mean?" He said, "Well, you are always saying they are 'dim and clear.'"
Saturday, August 15, 2015
Study: EKG goo soothes like VapoRub
 |
| The goo on the back of these stickers proven to work like Vick's VapoRub |
As a part of the study, 8 people complaining of shortness of breath and chest tightness were given an EKG upon admission to the emergency room, followed by two more every two hours, followed by one each morning until discharge. The control group of 2 patients all did not have EKGs done, except for the initial one in the emergency room.
All the patients who had serial EKGs eventually got better, except one male who developed nosocomial COPD and was disqualified. Both the patients in the control group developed physician acquired pulmonary edema and were both disqualified.
 |
| Not these! These don't resemble Vick's VapoRub |
Dr. Bill Senseless, who heads the Faux Pulmonary Research Project at the University, said, "The only conclusion we could make from this was that EKG therapy works to open up airways by osmosis through the skin to the airways. It works similar to Vick's Vapor Rub, only it's more profitable for physicians as we get $40 for just looking at the interpretation already on the EKG."
This study verifies the newly formed belief among the medical community that serial EKGs actually have therapeutic effects. It was for this reason that many health organizations have recommended a minimum of three minutes door to EKG time for all patients complaining of chest pain.
Further studies will not be performed to verify the results. However, a future study will be eventually prove EKG goo has real or perceived cardiac benefits.
Nausea, arm pain, hang nails, and rancid smelling patients are generally treated the same as chest pain and tightness. ACLS recommends a door to EKG time of 10 minutes for chest pain. The Real Physician's Creed recommends a door to EKG time of 10 seconds. Based on these recommendations, the Keystone Collaborate has succeeded in increasing the door to EKG time to three minutes so they have another reason not to pay if they don't want to.
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| Vick's VapoRub Not recommended. Makes stickers not stick |
Dr. Senseless said that he has already sent a recommendation to the Real Physician's Creed Association to look into adding an EKG as a top-line treatment for all patients who come to the emergency room complaining of shortness of breath. This should be performed immediately before or immediately after a bronchodilator, repeated Q2 times 3, then Qam.
"And this is the minimum we require," Dr. Senseless added, "If it makes a doctor feel better, more can be ordered. We actually had one nurse recommend an EKG because a patient had a stuffy nose, and it worked like a charm. She said the respiratory therapist complained about wasting his time and that this only worked because it made the patient feel like something was being done. We're used to such sniveling by RTs. We just know it works because because of the Vapo Rub Effect."
Friday, August 14, 2015
Aerosols no longer indicated for airway clearance
RT Magazine reports the following:
A new evidence-based Clinical Practice Guideline (CPG) published in Respiratory Care found that evidence is lacking that proves pharmacologic agents routinely administered for airway clearance are effective in improving oxygenation and respiratory mechanics, reducing ventilator time and ICU stay, or resolving atelectasis.
The CPG is based on the work of an American Association for Respiratory Care (AARC) task force and Vanderbilt University researchers.The following are the new recommendations regarding use of aerosols for
- The routine use of aerosolized acetylcysteine (Mucomyst) to improve airway clearance is not recommended in hospitalized adult and pediatric patients.
- Aerosolized agents to change mucus biophysical properties or promote airway clearance are not recommended for adult or pediatric patients with neuromuscular disease, respiratory muscle weakness, or impaired cough.
- Mucolytics are not recommended to treat atelectasis in postoperative adult or pediatric patients, and the routine administration of bronchodilators to postoperative patients is not recommended.
- There is no high-level evidence related to the use of bronchodilators, mucolytics, mucokinetics, and novel therapy to promote airway clearance in the studied populations.
This is vindication, of sorts, to all of us RTs who have complained for years that this type of therapy rarely results in the desired benefits. We'll have to wait and see if the medical profession eventually catches on to this new wisdom. Using history as our guide, this will probably occur in the year 2035.
Further reading:
Further reading:
Thursday, August 13, 2015
Are 'death panels' coming back?
It is simply a fact that doctors need to (er, should) have that talk with their patients regarding end of life care. Doctors must (should) explain end of life care, and must have patients fill out advanced directives.
The difference Obama and I have regarding this matter is how such a directive should be enforced. I tend to agree with men like Thomas Jefferson, James Madison, James Monroe, and Grover Cleveland, that such matters should be dealt with by the states and not the federal government.
I bring this up because of an LA Times article titled "Obama Administration Revives Plan Once Criticized as Death Panels." If the government gets to decide who lives and who dies, then I'm out. If the government gets to decide that a 90 year old grandma cannot get the pacemaker she needs and wants, then I'm out. If the government decides who lives or dies, I'm out. This is unacceptable in my book. This is the end of the slippery slope I think conservatives are worried about, and how terms such as "death panels" came about.
If the government is just doing this to save money, then I'm definitely out. When it comes to saving lives, money shouldn't matter. Human life is more precious than anything else on earth, even the earth itself.
However, if the goal is noble, then I'm all in. If the goal is to get people to make smart decisions about end of life care, then I'm in. I see too many people who want chest compressions and intubation who have no idea what that means. Too many people get it all when they shouldn't. I mean, I certainly don't want to be pounding on grandma's chest. If that's what grandma wanted, I'm fine with that. But a responsible doctor would have at least had that talk with her at some more (hopefully by choice and not by mandate).
So, it should be grandma's decision and not Uncle Sams. The government should have no say in who lives or who doesn't. And I certainly don't think the government should even get involved in this. They should not even offer negative incentives, such as they do with reimbursement criteria (if you don't do this we're paying you less. Negative reimbursement is basically a nice way of saying you have to do it or else. There really isn't much of a choice there.
Still, I think it's a noble cause if it's done right. It's a noble cause if there's an educational campaign that goes on, and not an Uncle-Sam-is-going-to-force-you-to-do-this-and-everyone-over-the-age-of 70-will-now-be-a-DNR-campaign. I think doctors should be encouraged to talk to their patients about end of life care. It would be a noble public relations campaign to get into -- but it should not be a law, nor a regulation, nor a mandate.
Further reading:
- RT Cave: How Do People Die
- RT Cave: Most People Will Not Survive CPR, but many want it anyway
- RT Cave: Is It Okay To Keep Patient Alive Until Family Arrives?
- RT Cave: Believe It Or Not, You Will Eventually Die
- RT Cave: The Elderly Are The Seat Of Wisdom
- RT Cave: He Died Peacefully In His Sleep
- Wall Street Journal: How Doctors Die Differently
Wednesday, August 12, 2015
Links between Genetics and COPD
The Impact of Genetics on COPD
Studies estimate that about 50 percent of smokers will develop COPD. So it’s obvious that some who smoke develop lung disease, but not all. It remains a mystery why this is. Most researchers speculate the answer has something to do with genetics.
The human body is composed of 37.2 trillion cells. Every cell has a nucleus, inside of which is a DNA molecule packaged in threadlike structures called chromosomes. DNA molecules consist of genes, which act as recipes for creating proteins. Each protein carries out some bodily function.
Most genes are the same in all people, although about one percent are unique, making every person unique. Unique genes are the result of gene mutations. Often these mutations are hereditary, and are handed down from parents. This might explain why some diseases, like asthma, are hereditary.
Other mutations are acquired during a person's lifetime. This might occur when a DNA molecule copies itself during cell division. This might also occur as a result of environmental exposure, such as to chemicals in cigarette smoke.
As far as the impact of genetics on COPD is concerned, very little is known. Here is some of what is known.
As far as the impact of genetics on COPD is concerned, very little is known. Here is some of what is known.
- Alpha-1-Antitrypsin. This is a protein produced by the liver that prevents the natural breakdown of lung tissue. Mutations in the SERPINA1 gene cause Alpha-1-Antitrypsin Deficiency. This results in the early development of emphysema even in those not exposed to cigarette smoke or other environmental triggers. This is the only specific genetic mutation known to cause COPD. It is hereditary. But this only explains 1-2 percent of COPD cases.
- Basal Cells. These are cells lining air passages that play a crucial role in producing other cells responsible for keeping the lungs healthy. They also replace lung cells that are injured or die. Researchers have discovered 676 genes in basal cells that were either over or under expressed in smokers. Four of these cells may be responsible for the early development of lung disease. One theory suggests that smoking causes them to reprogram basal cells to act abnormally. These changes are going on even in smokers who otherwise appear to be healthy.
- Inflammatory Response. Smoking may trigger some genes to initiate an immune response where inflammatory cells are recruited to the lungs. These inflammatory cells treat certain chemicals from cigarette smoke as an enemy, resulting in chronically inflamed airways, or bronchitis. Inflammation may also be responsible for the breakdown of lung tissue, or emphysema.
- Airway Remodeling. Some gene mutations may be responsible for airway remodeling, or airway changes, such as a thickening of the airway walls leading to permanent airway obstruction or narrowing.
- Lung Development. Hedgehog Interacting Protein is a protein that researchers think plays a role in lung development. They suspect it is produced on chromosome 7, and a COPD gene in this area may result in abnormal lung development, resulting in airflow obstruction. Researchers are keying in on various other locations where specific genes might be located that play a role in lung development.
- Asthma Genes. Another thing to consider is that researchers have discovered over 100 different genes responsible for asthma. It’s also possible that some of these genes, especially when exposed to chemicals from cigarette smoke, might also cause COPD. So some people might have a genetic code making them susceptible to both diseases.
- Heterogeneous. Every case of COPD is unique. This might be because the combination of COPD genes, or gene mutations, is unique in each person. This might explain why some COPD patients start to lose lung function earlier and faster than others. It might explain why COPD triggers vary from one patient to the next. It might also explain why each patient benefits from different medicine combinations.
Once the genes responsible for lung disease are discovered, researchers can focus on them to create treatment options to block their effects. Ideally, this will help those with COPD live better with it, and prevent our children from developing lung disease in the future.
Further reading:
Tuesday, August 11, 2015
Links between asthma and COPD
15 links between asthma and COPD
Asthma is no longer considered a Chronic Obstructive Pulmonary Disease (COPD). Experts now consider asthma and COPD as completely different disease entities with unique treatment regimes. Still, there remain many similarities, and here are 15 of them.
Past. Both diseases have a similar history. Asthma was defined for the medical community around 400 B.C. by Hippocrates. COPD was defined for the medical community about 200 years ago, although was probably confused under the umbrella term asthma prior to that. Somewhere along the way the roles were reversed and asthma was linked under COPD. Now they are both solo diseases.
Symptoms. Explaining why these two diseases were confused for each other for most of history is that symptoms are very similar. They both present with shortness of breath, chest tightness, coughing and wheezing.
Asthma is no longer considered a Chronic Obstructive Pulmonary Disease (COPD). Experts now consider asthma and COPD as completely different disease entities with unique treatment regimes. Still, there remain many similarities, and here are 15 of them.
Past. Both diseases have a similar history. Asthma was defined for the medical community around 400 B.C. by Hippocrates. COPD was defined for the medical community about 200 years ago, although was probably confused under the umbrella term asthma prior to that. Somewhere along the way the roles were reversed and asthma was linked under COPD. Now they are both solo diseases.
Symptoms. Explaining why these two diseases were confused for each other for most of history is that symptoms are very similar. They both present with shortness of breath, chest tightness, coughing and wheezing.
Triggers. Symptoms are caused by exposure to substances in the air that are innocuous (harmless) to most people, such as common allergens (dust, molds, fungus, pollen), cold winter air, strong smells, and exercise. Asthma triggers are similar, but not always the same, as COPD triggers.
Inflammation. They both are associated with chronic (it’s always there) inflamed air passages. This makes the air passages hyper-responsive (or over-responsive) to triggers.
Obstructive. Exposure to triggers causes an abnormal reaction that worsens inflammation and causes the muscles that wrap around the air passages to spasm, thus squeezing the airways. Increased sputum production further blocks air passages.
Acute. They are both associated with acute (it’s happening now) exacerbations. This is what we call asthma attacks or COPD flare-ups. Such acute episodes can be controlled and prevented (or the severity lessened) by following a treatment regime.
Reversible. Acute episodes of both diseases are reversible. However, asthma episodes are completely reversible, while COPD episodes are only partially reversible.
Intervals. Both present with intervals between acute episodes. Asthmatic lung function should be normal during intervals allowing asthmatics to live a normal quality of life between attacks so long as a treatment regime is followed. COPD lung function may always be somewhat compromised, although a treatment regime may improve lung function leading to an improved quality of life.
Chronic. Both diseases are chronic, meaning they are always there. For this reason, both asthmatics and COPDers must always work with their physicians to develop a treatment regime to prevent acute episodes, and plans for what to do when symptoms are observed.
Plans. Part of the treatment regime for both diseases is working with a physician to create either an Asthma Action Plan or COPD Action Plan. These help patients decide what to do when symptoms are felt and an acute attack/ flare-up is imminent or ongoing.
Medicine. Part of the treatment regime for both diseases also includes a combination of inhalers and nebulizer solutions to control and prevent symptoms. While some medicines are only approved for asthma (Advair), and some only for COPD (Breo), they are sometimes prescribed for either disease.
Diagnosis. There is no definitive test for diagnosing either disease. Diagnosis is usually accomplished by a series of tests (such as PFTs), symptom monitoring, and clinical assessment by a physician.
Beware. Sometimes asthma and COPD co-exist. Severe, untreated, or difficult to control asthma may lead to permanent airway changes and cause COPD. Smoking when you have asthma may also cause COPD. Still, sometimes COPDers have asthma and the reason is unknown. So there are times when these two diseases overlap.
Lifestyle. Most victims of these diseases will need to make certain lifestyle changes in order to make intervals long and episodes mild when they do occur. They must continue to work with a physician, learn to take medicine every day, and avoid triggers.
Future. Scientists and researchers continue to work overtime to learn more about these diseases, invent improved medicine, discover better treatment regimes, and provide hope for cures in the future.
Quality. Asthmatics should be able to live a normal quality of life. COPDers should be able to delay progression of the disease and remain productive members of society for many years. The trick is to work with a physician to develop a treatment regime that works for you.
Monday, August 10, 2015
Guidelines for expired asthma medicine
Is it okay to use expired asthma medicines?
With the ever increasing cost of COPD medicines I get a lot of questions such as, “Is it okay to use expired asthma medicines?” My answer usually goes something like this: “While it’s not necessarily recommended, it might work.”
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 there is not much science behind the date on the medicine.
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.
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.
Still, even after the expiration date has been reached the medicine will still contain some potency. How potent the medicine is is essentially a gamble, which is why expiration dates exist in the first place.
Personally, when I was a kid anyway, I have been known to find an albuterol inhaler stuffed inside a couch cushion only to find that it was expired. Usually I can tell it’s expired by the rotten mind taste, but these expired inhalers seem to work just fine.
Now that I’m an adult I try to avoid expired asthma medicines, yet if I were in a financial crunch, I would feel just fine about using expired asthma medicines, so long as it wasn’t too far beyond the expiration date. I mean, if it’s been expired a year, fine. But if it’s been two years, I’d probably toss it.
The question then becomes: Are expired COPD medicines safe? While some medicines become less safe over time, all the evidence I have found indicates that all asthma medicines are still safe even after the expiration date.
So safety is not an issue when using expired albuterol, Advair, Symbicort, and Dulera inhalers. The same is true of albuterol and levalbuterol solution. The taste might be a bit awkward, but they will still have some potency.
I have even had patients who tell me their doctor gave them free samples that were expired. With the high cost of asthma medicines these days, using expired asthma medicines is an option, if not a last resort option.
With the ever increasing cost of COPD medicines I get a lot of questions such as, “Is it okay to use expired asthma medicines?” My answer usually goes something like this: “While it’s not necessarily recommended, it might work.”
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 there is not much science behind the date on the medicine.
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.
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.
Still, even after the expiration date has been reached the medicine will still contain some potency. How potent the medicine is is essentially a gamble, which is why expiration dates exist in the first place.
Personally, when I was a kid anyway, I have been known to find an albuterol inhaler stuffed inside a couch cushion only to find that it was expired. Usually I can tell it’s expired by the rotten mind taste, but these expired inhalers seem to work just fine.
Now that I’m an adult I try to avoid expired asthma medicines, yet if I were in a financial crunch, I would feel just fine about using expired asthma medicines, so long as it wasn’t too far beyond the expiration date. I mean, if it’s been expired a year, fine. But if it’s been two years, I’d probably toss it.
The question then becomes: Are expired COPD medicines safe? While some medicines become less safe over time, all the evidence I have found indicates that all asthma medicines are still safe even after the expiration date.
So safety is not an issue when using expired albuterol, Advair, Symbicort, and Dulera inhalers. The same is true of albuterol and levalbuterol solution. The taste might be a bit awkward, but they will still have some potency.
I have even had patients who tell me their doctor gave them free samples that were expired. With the high cost of asthma medicines these days, using expired asthma medicines is an option, if not a last resort option.
Sunday, August 9, 2015
The Four Types of Pneumonia
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| A 1930 edition of the Real Physician's Creed. It's now so huge it's non-photogenic. |
On page 304,403, of edition 4,432, is a note describing the three types of pneumonia. Listed they are as follows:
1. Walking Pneumonia: Don't have it but something must be ordered to make everyone happy.
2. Pneumonia. They really have it and you can see it on the x-ray and everything. Or, as noted, sometimes you can hear it via crackles before you can see it on x-ray. Or, the white blood count is elevated, indicating there is an infection somewhere so it might be pneumonia. It is generally lobal and caused by a bacteria. Treatment is antibioitic to treat the infection and systemic corticosteroids to treat the inflammation. However, you may also treat it with ventolin because one study showed it enhances sputum production which, uh, somehow is twisted into making some doctors think it... well, it does help, errr, bring up the pneumonia... IT JUST DOES!!!
3. Faux-pneumonia. The patient doesn't have it, but you need a better diagnosis than walking pneumonia in order so that the patient may meet criteria. You can see it on the x-ray only if you have the superior vision abilities only taught in medical school, which can be found on page 3,133 of the Creed. (I at present do not have a copy of that page, as this part of the book I have has been destroyed by too many coffee stains).
4. Double Pneumonia. They have twice as much pneumonia than the average person who actually has a diagnosis of pneumonia, which some call real pneumonia as compared with faux pneumonia. It is generally caused by a virus and is deadlier than regular pneumonia. Treatment is to hit it with everything, including systemic corticosteroids to treat inflammation, antibiotic to treat the infection, ventolin to help the patient cough up the pneumonia, and anything else you feel like throwing at it. Usually it involves treating the symptoms. Treatment is generally supportive.
Further reading:
Further reading:
Saturday, August 8, 2015
Respiratory therapists lazy?
Look at it this way. No one wants to suction. But sometimes we have patients that definitely need it. In these cases, we might go out of our way to ask a physician. If we do this, consider that it is definitely needed. I mean, not only is suctioning invasive and uncomfortable for the patient, but it's a lot of work for us RTs. So, if we ask for it, it's needed.
Consider ventolin. I mean, any respiratory therapist understands that we give enough ventolin out to suffer deeply from second hand ventolin (grumpiness, apathy, increased wisdom, the ability to tell the difference between heart failure and pneumonia from bronchospasm without even assessing the patient). So if we ask for a new breathing treatment order, you gotta admit it's probably needed.
We also complain to nurses (at least under our breath) about new treatment orders. We say things like, "Um, this patient is in heart failure. He doesn't need ventolin." But the nurse calls us on it, saying things like, "You're just being lazy. Cure the patient's wheeze with your magic mist."
Sorry, we are lazy. Well, not really.
Quote by Ron Burgendy: "I may not know all the facts, but I always tell the truth."
Quote by Ron Burgendy: "I may not know all the facts, but I always tell the truth."
Respiratory Icon dies
Most people don't realize this, but some of the initial respiratory therapy equipment was developed in an effort to win WWI and WWII. Dr. Bird was an innovator and inventor during WWII, and his aim was to develop equipment that would help pilots fly higher. He understood that if they could fly higher they could more readily evade enemy planes and escape enemy fire.
After the war he turned his efforts to helping anesthesiologist Roger Manley invent a machine that could be used to safely ventilate patients during operations. At this time the only means of breathing for patients were rogue techniques that were relatively unsafe. Please consider that even the AMBU-bag wasn't invented until 1953.
In 1946 the Manley Ventilator was introduced to the market, and in 1950 it was updated followed by the 1950 first prototype of the Bird Respirator with advanced positive pressure. It was later refined by Bird and renamed the Bird Mark II.
This machine essentially rendered the negative pressure ventilator, or the famous iron lung, obsolete.
The machine was neat because it allowed anesthesiologists to ventilate patients without using either manpower nor electricity. The machine was pneumatic, meaning that the only power source needed was a 50 PSI source of air.
By the 1975 he introduced an updated version of the machine called the Bird Mark 7, a small green box that became famous to both respiratory therapists and their patients. It was used as a ventilator, but it became more commonly famous for its use as a machine that became known for delivering intermittent positive pressure breathe (IPPB).
It was very commonly used in hospitals both as a ventilator and as an IPPB machine. The volume ventilator ended the reign of the IPPB machine being used as a ventilator, although the 1970s gave rise to the IPPB machine being used to deliver medicine.
It was falsely believed for years that the breaths provided by the machine resulted in better distribution of medicine. It was also falsely believed to prevent post operative atelectasis and pneumonia.
However, like most respiratory myths, the IPPB machine was later proved to do nothing more than overdistend good alveoli.
Regardless, it was a very useful invention that was put to good use during the 1940s and 1950s. Yet even while clinical evidence suggested it outlasted its usefulness, physicians continued to order IPPB treatments well into the 2000s.
Where I work, we still have one in our storage room, although I have not had to use the machine since our hospital hired hospitalists who know that all it did was over extent good alveoli. Our machine is now used as a coat hanger for my lab coat. When I go to work on Monday I will take a picture of it and post it here.
He later invented other machines to help both anaesthesiologists and respiratory therapists ventilate patients. One such machine was the Baby Bird, introduced in 1970, which was a complicated ventilator that was used to breathe for infants.
When I became an RT in 1995, it was the back up ventilator at General Hospital in Muskegon and it was mainly used to scare us new RTs. The seasoned RTs would show us it and explain to us how we had to use our watch to time breaths. Yeah, it was not fun. Thankfully I never had to use it. Still, I bet it was very useful during its time: The Baby Bird is thought to have helped reduce infant mortality from 70% to 10%.
I will be publishing a history of respiratory therapy on my blog "Asthma History," and Roger Bird will play a significant role in this history. So, we here at the RT Cave would like to bid farewell to one of the greatest minds in respiratory care. Perhaps without his innovations, we may not be where we are today as a great profession.
Further reading:
In 1946 the Manley Ventilator was introduced to the market, and in 1950 it was updated followed by the 1950 first prototype of the Bird Respirator with advanced positive pressure. It was later refined by Bird and renamed the Bird Mark II.
This machine essentially rendered the negative pressure ventilator, or the famous iron lung, obsolete.
By the 1975 he introduced an updated version of the machine called the Bird Mark 7, a small green box that became famous to both respiratory therapists and their patients. It was used as a ventilator, but it became more commonly famous for its use as a machine that became known for delivering intermittent positive pressure breathe (IPPB).
It was very commonly used in hospitals both as a ventilator and as an IPPB machine. The volume ventilator ended the reign of the IPPB machine being used as a ventilator, although the 1970s gave rise to the IPPB machine being used to deliver medicine.
It was falsely believed for years that the breaths provided by the machine resulted in better distribution of medicine. It was also falsely believed to prevent post operative atelectasis and pneumonia.
However, like most respiratory myths, the IPPB machine was later proved to do nothing more than overdistend good alveoli.
Regardless, it was a very useful invention that was put to good use during the 1940s and 1950s. Yet even while clinical evidence suggested it outlasted its usefulness, physicians continued to order IPPB treatments well into the 2000s.
Where I work, we still have one in our storage room, although I have not had to use the machine since our hospital hired hospitalists who know that all it did was over extent good alveoli. Our machine is now used as a coat hanger for my lab coat. When I go to work on Monday I will take a picture of it and post it here.
He later invented other machines to help both anaesthesiologists and respiratory therapists ventilate patients. One such machine was the Baby Bird, introduced in 1970, which was a complicated ventilator that was used to breathe for infants.
When I became an RT in 1995, it was the back up ventilator at General Hospital in Muskegon and it was mainly used to scare us new RTs. The seasoned RTs would show us it and explain to us how we had to use our watch to time breaths. Yeah, it was not fun. Thankfully I never had to use it. Still, I bet it was very useful during its time: The Baby Bird is thought to have helped reduce infant mortality from 70% to 10%.
I will be publishing a history of respiratory therapy on my blog "Asthma History," and Roger Bird will play a significant role in this history. So, we here at the RT Cave would like to bid farewell to one of the greatest minds in respiratory care. Perhaps without his innovations, we may not be where we are today as a great profession.
Further reading:
Wednesday, August 5, 2015
Researchers discover cause of pulmonary fibrosis
What has been known is that repeated exposure to various substances -- such as an infection, drugs, or inhaled chemicals -- may irritate the interstitium, or tissue that lines and supports the alveolar air sacs, causing it to become inflamed, and then increasingly scarred and thickened. This makes it so oxygen is unable to diffuse across alveoilar-capillary membranes. This results in progressively worsening and irreversible dyspnea.
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| Pink = Chromosome Green = Telomeres |
At the present time treatment is generally supportive, such as oxygen therapy and anxiolytics.
Researchers now believe that the causative agents may cause damage to telomeres that are present in every cell in the human body. Telomeres are the caps of DNA that protect our chromosome, like the plastic tips on the ends of shoelaces. They prevent the strands of DNA, and therefore the cell, from breaking apart. When they do break apart this in essence speeds up the aging process.
The researchers discovered that some mice lacked a protein necessary to build telomeres in a specific cell population. By studying these mice, they learned that they develop progressively worsening pulmonary fibrosis similar as to what occurs in the human population.
They also learned that lack of telomeres is lethal to type II alveolar cells, making it so epithelial cells cannot regenerate and cannot repair damage. This results in the natural breakdown (aging) of the cells causing them to become inflamed, resulting in increased scarring and thickening (fibrosis).
While this was only one research project, it should give something to focus on with the hopes of coming up with some form of treatment for this condition that is more than just supportive.
Further reading:
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