I am inspired by my readers

I didn't really have a lot of patient on the floors last night when I worked, but ER was absolutely swamped. I was paged down there at one point to do "Several EKGs." When I arrived, I found there were seven EKGs for me to do.

"We're running a Blue Light Special on EKGs tonight. Anybody else want one?"

Finally around 3:00 in the morning ER gave me a break, and I needed to find something to entertain myself. I was way to tired to write anything intelligent, so I did an IceRocket Blog Search to see who was talking about the RT Cave, if anyone.

This is not something I do on a regular basis, but I was pooped out after working the entire 4th of July weekend. With all the vacationers we have in this town, I'd say about half of them were right here in our ER. Oh, and of course they all needed an EKG and a treatment.

So, I found that a story I wrote a few months back called, "The five different types of COPD patients," was posted and being talked about in a couple COPD community websites. I thought this was so cool.

One such website was COPD International. It was really cool reading all the nice comments about this post, and my blog in general. I will be honest here: I expected when I started this blog that I might get some fellow RT readers. But I never would have guessed in a million years that I would acquire a following of patients.

To me, the fact that patients find entertainment in my RT humor, or useful information from my insights and informative posts, brings me great joy.

Here is my favorite comment: "Thanks Annie most interesting I went to the source and what a wonderful site. Kind of like being behind the door. If you know what I mean."

Kind of like being behind the door. If you know what I mean.

What a cool comment. I might have to steal that and use it in my header, if I ever figure out how to make one that's cooler than what I currently have.

Here's another cool comment: "I'm glad you went to his blog, Madblue. It IS interesting to see this disease from a care giver's point of view...especially from one who has been trained to help COPD patients."

I guess I never really think of it this way. You know what I mean? I write because I love writing. I write about things I am passionate about. I write because there are things in this career field that are great, and then there are things that could be better.

And, if I wasn't optimistic that change were possible in the RT business, I probably would still continue to write on this blog, because there is a certain amount of knowledge base in my head, in all our heads, that others can benefit from.

The fact that I discover that people are reading my blogs and then posting my writings on other websites because they are entertained by what I write, is an absolute honor for me. It inspires me to keep writing.

So, I suppose, by me writing this post, I am saying Thanks.

And that, my fellow readers, is the thought of the day.

Oxygen therapy: Stripping the threads

I always tell my patients that the hardest part of the job is screwing stuff into the oxygen flowmeters. It's something I never really think of except for when I'm in the process of doing it, so it's my patients I usually mention it to.

And I've had patients, or nurses, laugh at me as I struggle to screw on that nipple adaptor (often referred to as Christmas Trees), or that bubbler, onto the flowmeter. And I grumble and gripe as I try again and again to get it to screw on just right without stripping the plastic threads.

That has got to be the hardest part of this job. It's not so bad when a patient doesn't require a bubbler, but when a patient has a bubbler, and a treatment is indicated, you have to unscrew the bubbler and screw on the nipple adaptor. Those cheap nipple adaptors never seem to go on just right.

Yet, if you aren't patient, and you strip the threads, you have to walk all the way to the supply room to get a new one, that is unless you just so happen to have a spare in your pocket, of which I usually do except for when I need one.

And then, once the treatment is done, you have to thread the bubbler back into place.

Sometimes, as I struggle to do this, I find myself thinking maybe I should just say "screw it," and leave the nipple adaptor in place so I don't have to go through this process again in four hours. But, being the good RTs we are, we have to do the right thing and hook the bubbler back up.

Today, though, as I was doing my last treatment, I thought that when you have a code, you never seem to have a problem hooking up the AMBU bag to the flowmeter. That's because these things are designed to be fool proof, so you can just plug it onto the flowmeter.

My thought was, why can't nipple adaptors and bubblers be that easy? Why do we have to screw the darn things on? Why can't some entrepreneur invent an easy way to hook stuff up to flowmeters.

Thankfully, I never have a problem screwing in the ventilator tubing, but those things aren't made out of plastic either. I think it's the cheap plastic that causes this frustration. I suppose that's the cost we pay for cheaper, disposable equipment.

I searched the Internet to see if maybe some company had made a screwless nipple adaptor, but I have yet to find one. However, I suppose it really doesn't matter, because hospitals usually sign contracts, and get whatever supplies are provided by the one company.

So, I suppose we'll continue to be stuck with these cheap plastic nipple adaptors, and cheap plastic bubblers that never seem to want to thread on easy, or at least not when we are in a hurry.

That, my friends, is the thought of the day.

New hope for those who want to quit smoking

We as RTs are constantly working with patients who smoke. In fact, if people ever did stop smoking we might simply be out of a job.

In fact, one of the ironies of the medical field, is we make a conscious effort to do thing to that we think will benefit other people but ultimately put ourselves out of work. It would be like Marborro heading an anti-smoking campaign.

We here at the RT Cave have this neat little pamphlet we give to our patients who want it, and it provides some awesome information about the dangers of smoking and how to quit. I'm sure your hospital does too.

In doing my daily search of blogs last weekend, I found my way to COPD News of the Day, where she reports that "kicking the habit may become easier for the nation’s 45 million smokers.

For the first time, researchers have identified patterns of genes that appear to influence how well individuals respond to specific smoking cessation treatments."

Anything that would make it easier for people to quit is good news, even if it extinguishes our jobs in the process.

I also found this article about how researchers have linked smoking with midlife memory loss. Yet another reason for people to quit, or to not start in the first place.

Asthma/COPDers should avoid pop & beer

One of the things I regret most about when I finished the RT program is my decision to burn all my notes. Little did I know some day I'd have a yearning for all those superfluous facts I incinerated.

My RT Student today reminded me of one of those fact I had all but forgotten. She said, "Did you know that pop and beer can be bad for COPD and asthma patients?"

"Yes I did," I told her, "But I had forgotten."

This is the kind of information we don't use on a regular basis here in the hospital, but it is something to keep in back of our minds as we take care of COPD patients. We should know why it may not a good idea for that COPD patient to have that Diet Coke or Sprite.

Being the good RT Blogger that I am, I had her dig through her notes for more information regarding this, and she made me a copy of her class notes for that day. I'm not sure who the teacher's source for this information was, so I'm just going to attribute this to general RT knowledge.

According to the information she provided me, here are some basic facts:

• The normal human body breathes to eliminate CO2, producing 200cc per minute that has to be eliminated at the same rate.


• One can of soda contains up to 1000cc of dissolved CO2, most of which is absorbed into the blood stream by the intestines.


• The Lungs are presented with the extra CO2 to eliminate by increased minute volume leading to increased respiratory effort.

A normal individual won't have a problem with this extra CO2, as the extra CO2 absorbed via the intestinal track will signal the central chemoreceptors to "immediately" increase the respiratory rate (click here to see why we breath).

However, for a patient who already has a compromised respiratory system, such as symptomatic asthmatics and chronic lung patients, this extra CO2 may cause problems.

Simply put, they may not have the lung capacity to increase their respiratory rate enough to blow of the extra CO2, and this may cause additional dyspnea and further aggravate respiratory failure.

Since it takes longer for them to normalize their CO2 level, that can of pop could actually "aggravate their acid base problems."

In short: "Carbonated beverages will increase the respiratory efforts in normal individuals; but symptomatic asthmatics and COPDers will need to exercise caution when consuming carbonated beverages."

Carbonated beverages can also cause excess gas and bloating, which may result in the diaphragm being pushed up against the lungs, further compromising them and making it even more difficult to breathe.

Beer is something that symptomatic asthmatics and COPDers might also want to consider avoiding because it also has a tendency to cause dehydration.

When your body is dry, your lungs become dry, and this may further exacerbate breathing difficulties.

This is just another example of how lung patients have to think about things that normal people simply take for granted.

The hypoxic drive theory: Should be still taught

(This is part six of a six post series. To view entire series click here. )

I'm enthralled with this hypoxic drive theory, so I have to make one more post about it, and then I will probably never mention it again. But I can't help but to delve into this topic, to smell it, to read Jeff Whitnack's rantings with awe.

After all, I have been on a rampage myself on my own RT Cave blog about bronchodilator reform. I think doctor's and nurses have been inculcated with the idea that bronchodilators are indicated for everything pulmonary, when they are really only indicated for COPD and asthma.

So, I can hear Whitnack's frustration.

He writes, "When I bring up my arguments against the hypoxic drive, often I feel as if I am arguing religion and not science."

I feel the same way when I argue for bronchodilator reform. I often feel as though I'm blowing into the wind, and will never win. However, I cannot stop trying.

There is a reason I wanted to make this one last post about the hypoxic drive, and it has to do with this quote from Whitnack's RRT Page: "I have asked local RT instructors their opinion. One said, 'I don't believe in it (CO2 retainer/hypoxic drive theory), but I've got to teach it.'"

I discussed my opinion about the hypoxic drive theory being a fallacy with one of my RT students a few weeks ago. After I brought it up with her I wished I had not, because I decided I shouldn't confuse her, considering she would be taught the hypoxic drive theory in school, as I was by her same teachers.

However, she came back the next week, and she reported that she told her teachers about what I said. Her teacher said, 'There is a lot of evidence against the hypoxic drive theory, and we are actually thinking about not teaching it anymore.'"

That is definite progress.

However, I would have one thing to say to this teacher, which may surprise you guys:

I would not stop teaching the hypoxic drive theory.

Are you shocked that I'm saying that?

Well, you wouldn't be if you read my other blog. Because I believe that all theories should be taught in school, and that the students should be allowed to decide for themselves which is real and which is fallacy.

Because, after all, these are just theories. And, either way, there will still be doctors for years to come who are "brainwashed" into the idea that the CO2 retainer/ hypoxic drive theory is as real as the screen you are reading this on.

Overall, as per this slide show: (source unknown) "Health care providers need a clear understanding of the risk factors associated with oxygen induced hypercapnia... This knowledge needs to be applied in clinical practice to select patients to be identified at risk for oxygen induced hypercapnia instead of withholding treatment to all patients with the diagnosis of COPD"

Anyway, I hope my posts, coupled with Whitnacks, and other sources floating around or available for free on the Internet, will help make other RTs, RNs and doctors, and -- probably more important -- teachers aware that the hypoxic drive theory has been "debunked," and replaced with a greater concern, which is oxygen induced hypercapnia.

Wait!! There is one more thing that is more important than what we RT thinkers think: the patients. If we can show that it is okay to have a COPD patient on more than 2 LPM, then the person who benefits is the COPD patient.

I lied about one thing. I WILL definitely bring up this hypoxic drive theory again, as I have just recently been contacted by a COPD patient who personally does not believe in the theory. As soon as she gives me permission, I will write more. Her story is very inspirational.

Thus, more coming...

The hypoxic drive theory: The CO2 retainer

(This is part three of a six post series. To view entire series click here.)

Today I would like to add to our discussion of why people breath. In particular, today's post will delve further into the topic of oxygen induced hypoventilation.

As we described earlier, the body will continually try to make sure that gases in the body are balanced in order to maintain a normal pH, and in this way maintain a certain level of homeostasis within the body.

Usually, increases and decreases in carbon dioxide levels detected by the central chemo receptors is what causes people to breath. When a person is in respiratory failure, and the carbon dioxide level is high, decreasing levels of oxygen as detected by the peripheral chemo receptors then takes over as the drive to breath.

Thus, if a person has a chronically high carbon dioxide level, and you give this person 100% oxygen, you knock out their drive to breath. This, my friends, is what we call the hypoxic drive theory. Actually, this is the gold standard of respiratory care. It is what helped to establish us as a profession.

According to Donald Egan's "Fundamentals of Respiratory Care," when a normal person "breathes 100% oxygen, the peripheral chemo receptors remain essentially inactive. However, because blood oxygen levels are high, there is less reduced hemoglobin available to carry carbon dioxide. This causes a slight rise in (carbon dioxide) CO2, which in turn stimulates the medullary respiratory center (at the base of the brain)." This in turn causes a person to breath faster.

Now, if you have a patient who has a chronically low level of oxygen and high level of CO2, breathing high levels of oxygen (FiO2) can cause a person to slow down his breathing. In essence, the "high blood O2 (oxygen) levels suppress these peripheral chemo receptors, thereby depressing ventilatory drive."

Since a person's breathing is how they blow off excess CO2, you can see how this could be detrimental to a person who already has a high CO2 level.

Thus, since the high FiO2 (say 100%) is signalling the peripheral chemo receptors to slow down breathing, a person with a chronically high CO2 may end up with a critically high CO2. In cases like this, I've seen CO2s in COPD patients as high as 110. This is not good. And usually these patients become lethargic.

Usually, according to William A. French, "Hypoxic Drive Theory Revisited," rtmagazine.com (Issue: February/March 2000), CO2 must generally reach a level above 90 mm Hg for" a patient to become lethargic.

However, sometimes these patients are so used to high CO2 levels, that they remain conscious even with a high CO2 level. If you have ever seen a COPD patient in this situation, you will observe that they are usually blue, and this is where we get the term blue bloaters from. The patient is blue due to low oxygen.

And they also are jittery or shaky. That is the high CO2 at work. If they are lethargic, that is usually due to the high CO2 level, but as the hypoxic drive theory states, it may also be due to the high level of oxygen the medical staff provided to the patient.

That is the theory. Keep in mind it is a theory that doctors believe in to the point of ad nauseam. I personally think it is inhumane to allow a person's oxygen to stay low, when this could kill them. However, that's just my opinion.

This brings me to my next point. According to Egan himself, right in his book. And I think it is these next two paragraphs that will help me disprove the hypoxic drive theory, of which I will attempt to do in my next couple posts.

Egan writes that "the rise in PaCO2 that is observed in some patients is due mainly to impaired gas exchange, not depression of ventilation."

And, he writes:

"Regardless of mechanism then, hyperventilation is a potential hazard of O2 therapy in patients with chronic lung disease, however, this harmful effect should never stop us from giving oxygen to a patient in need. Preventing hypoxia should always be the first priority."

Thus, according to Egan, "in order to prevent hypoxia but avoid hypoventilation (breathing to slow down) in these patients, we should aim for an arterial PO2 between 50 and 60 torr. Generally, this approach provides adequate oxygenation, while minimizing the likelihood of hypoventilaiton."

In layman's terms, a normal blood PO2 is over 100. A PO2 of 100 would usually generate a sat (SPO2) of about 98%. A PO2 of 50 to 60 would therefore generate a sat of 80 to 90%. So, if you werent' familiar with these medical terms, now you are. And now you know what to look for on the monitor besides heartrate, respiratory rate and blood pressure.

To maintain a sat of 80 to 90%, usually we RTs use 2-3 LPM via nasal cannula. Or, if a patient needs more oxygen, or is breathing laboriously, we will use a venti-mask at no more than 30 to 40% FiO2 (oxygen). (For the record, there is 21% oxygen in the air you breath).

However, what happens if a chronic COPD patient is on a 40% venti-mask and is sat on the monitor still reads 70%? Now what do you do. You give them more oxygen. You give them 100% oxygen if they need it.

Or, as I've seen many times, you walk up to the doctor to get an order for more oxygen, and he says, "keep it right where it is. We don't want to knock out his drive to breath." And he looks at you like you are an idiot.

Or, another scenario is you do a blood gas that shows a PO2 of 45 and a CO2 100. The patient is awake and alert and talking to you just fine. The doctor says, "decrease the oxygen. We need to see if we can get that CO2 down."

This is where you roll your eyes in frustration.

To be continued...

The hypoxic drive theory: Why do we breathe?

(This is part two of a six post series. To view entire series click here.)I finally have time to write, so I will delve into a topic I promised long ago: Is the Hypoxic Drive Theory fact or fiction.

When you are thinking about it, you can control your breathing on your own. Most of the time you are alive, however, you will have better things to think about than your breathing. And when you do, your body will keep on breathing.

How does this work? All you RTs our there studied this in school, but if you are like me, teachers make this stuff so complicated that you remembered it until the test was over. That in mind, my effort here is to keep this review quick and simple, so anyone can understand it.

If I blow past you, here is a quick reiview of how we breath you can read.

There are basically two reasons for breathing. One is to maintain homeostasis within the body, and the other is for the exchange of gas. By homeostasis I mean maintaining a normal level of oxygen(PO2), carbon dioxide (CO2) and acid base balance (Ph) or hydrogen ions. By exchanging gas, I mean breathing in oxygen, and blowing out CO2.

According to Donald F. Egan's "Fundamentals of Respiratory Care", breathing is controlled by the Central Nervous System, and originates "in the brain stem, mainly from neurons located in the Medulla Oblongata. For the most part, and skipping a bunch of crummy detail, this gland controls breathing by messages it receives from Chemo receptors.

There are two sets of chemo receptors: the central and the peripheral. The central sit right on the Medulla, and the peripheral are located in the "bifurcations" of both carotid arteries and the arch of the aorta, or somewhere between your shoulders and above your heart.

These chemo receptors send messages to the brain (the Medulla) based on changes in CO2 and PO2. However, for the most part, the main driver of non-spontaneous breathing is carbon dioxide (CO2) way more so than oxygen (PO2).

Allow me to put it simple, when CO2 goes up above a certain point, your breathing speeds up. This is evident quite often in COPD and asthma patients who are suffering an exacerbation. They are having great trouble breathing, and ultimately they start to poop out, and their CO2 starts to build up. Thus, their breathing speeds up.

A normal CO2 is 40. Say it goes up to 100. By this point, when CO2 is 20% or greater above the normal value, CO2 starts to act like a sedative, and slows breathing down. Thus, as CO2 continues to rise, this is a sign doctors watch out for that a person is pooping out, and may need aggressive therapy.

The majority of the time, the central chemo receptors send signals to the brain that control breathing. The peripheral chemo receptors only have a minor roll during normal respirations, and only send a signal to breath when the PO2 is less than 60. Either way, this response is far slower than the signal sent by the central chemoreceptors. Thus, the peripheral chemoreceptors only play a minor role in breathing, unless a patient is a chronic CO2 retainer, of which we will discuss in a moment.

Thus, we will focus on the central chemo receptors for purposes of simplicity.

Let me confuse you a minute. The real drive of breathing is actually hydrogen ions . As hydrogen ions increase, your breathing speeds up. But, since hydrogen ions are not allowed to cross the blood brain barrier so that the pH of the brain can be different from the pH of the body, it cannot directly be used to stimulate breathing.

Thus, CO2 is used. CO2 is allowed to cross the blood brain barrier. Excess levels of CO2 arrive in the brain and are received by the Central Chemo receptors. Thus, "elevations in CO2... cause rapid diffusion of the gas into the CSF (Cerebral Spinal Fluid), where it dissociates into hydrogen ions and lowers the CSF, thereby stimulating the central chemo receptors. The central chemo receptors, in turn, signal the medulary centers to increase ventilation."

So you can see, CO2 "indirectly" causes changes in reparations.

If the CO2 becomes chronic, or is still hanging at a high level after a day or two, according to Egan, the stimulatory effect of the high CO2 diminishes because the kidneys will try to compensate for the high CO2 by creating more buffers (bicarbonate or HCO3), thus causing the pH of the CSF to go back to normal. The medulla thus receives a signal that CO2 is normal, even though it is actually elevated.

It therefore is easy to tell which patients are chronic retainers because their HCO3 level will usually be high, and usually something greater than 30.

And, in Chronic COPD patients, this CO2 level may stay high while at the same time maintaining homeostasis (a normal pH), and thus CO2 has less of an effect on breathing as it would on a normal person. In effect, it may be normal for a COPD patient to have a CO2 of 50, and a PO2 of 50. We call these guys members of the 50/50 club, or chronic CO2 retainers or simply chronic retainers.

Changes in PO2 have no direct effect on Central Chemo receptors.

As anything in life, this process is far more complicated than I just explained, but you can see from what I have described here why in many COPD patients CO2 may lose its ability to stimulate a person's drive to breath, especially when CO2 is chronically elevated.

And this is where the gold standard of RT comes into play. As, when a patient has a chronically elevated CO2, it is believed that it stops being the drive to breath. In these patients, it is believed that oxygen becomes their main drive to breath.

Thus, we must take a look at peripheral chemo receptors. According to Egan, "Peripheral chemo receptors are very not sensitive to CO2 changes... their primary role appears to be in response to hypoxia."

Normal PO2 is 104. It does not effect the peripheral chemo receptors until it is less than 60. To put this in perspective, a PO2 of 60 will usually generate a sat (SPO2) of about 90%. As the PO2 falls from 60 to 30 torr (SPo2 of 90% to 60%), the rate of breathing should be expected to be increased due to signals sent from the peripheral chemo receptors.

Now, as we've explained, CO2 is normally the drive to breath. But, if a patient with COPD is having so much trouble breathing that there is no way possible that he can speed up his breathing further to blow off that excess CO2 "regardless of patient effort," CO2 no longer is the drive to breathe, and PO2 becomes the drive to breathe.

This is called the hypoxic drive theory.

And this, my fellow readers, is why doctors soooooo do not want to put a COPD patient on more than 2LPM even though their oxygen levels continue to be low.

This is why many COPD patients are allowed by many doctors to have sats in the mid to low 80s even though low levels of oxygen may be deadly to the heart. This is why many doctors refuse to put many COPD patients on 100% oxygen, because they are afraid they will knock out their drive to breath. They are afraid the patient will become lethargic and die.

The hypoxic drive theory is the gold standard of respiratory therapy, but is it a fallacy or a reality. This is a debate that may be ending.

To be continued...

"I'm not sorry I have COPD," she said

"You don't know what it's like to sleep in these beds," Mrs. Patient said, and smiled. It was the first time I had seen her smile in the two days I had taken care of her.

"You might be surprised," I said, preparing my syringe to draw my a.m. ABG.

"How could you possibly know what it's like to sleep on these uncomfortable mattresses?" She was admitted with exacerbation of COPD, and had been requiring a bronchodilator at least every two hours until today. She was looking pretty comfortable all slouched down there on the bed.

"You might be surprised. "I grabbed her hand, knelt alongside her and held her hand, feeling for her pulse.

"Usually they get it on the other hand. They keep missing on that one."

" I feel a great pulse here." I uncapped the syringe.

"Okay, I'm ready." I'm not poking you yet. I'll warn you when I'm ready."

She relaxed and smiled again. "So what did you mean I might be surprised."

"Because I slept in this very bed in December. I know how uncomfortable it is first hand." The needle pierced the skin. She did not flinch.

"You did, really?"

As she pondered that, I watched as the blood flowed quickly and smoothly into the syringe. I pulled out the needle and held her wrist with a pad of white gauze. "Yeah. I know exactly what these beds are like."

"What was wrong with you."

"A bleeding ulcer."

"How bad was it that you had to be admitted?"

"I lost four units."

"Oh, I guess that's bad. How does a young man like you get an ulcer?"

"It was probably secondary to asthma medications, I guess. Or a bacteria. No one really knows for sure."

"Oh, you have asthma."

"Yeah, I've spent my fair share of time in hospitals for it, but not in the last ten years." I removed the gauze. She was still bleeding a little. I held pressure again.

"Oh, I'm sorry."

"I'm not. I wouldn't have this job, and I wouldn't have my wife, and I certainly wouldn't enjoy writing if I didn't have asthma."

"That's a good attitude. You know what, I'm not either. I mean, about my COPD. I'm not sorry I have COPD." She smiled. "There's people who have it a lot worse than I do."

I didn't say anything to that for a few minutes. I thought of the irony of that statement. Here she was knowing she may never breath normal again, and probably will spend the rest of her life thinking about every breath, and she says she doesn't feel sorry for herself, that there are people far worse than her.

Finally I broke the silence. "I love that attitude in a patient."

She smiled. "You didn't get bad lungs because you smoked, right?"

"That's correct." I plastered a bandage over the gauze and stuck it on tight. "All done."

"That didn't even hurt at all," she said, looking down at her wrist.

"Thanks."

I grabbed the capped syringe and got up to go. She said, "I made myself this way. I destroyed my own lungs."

"When did you start?"

"When I was 17. I quit for five years believe it or not, then I started up again and smoked for 40 years. How stupid was that?"

"To your defense, though, back when you started you probably didn't hear all the time how bad cigarettes were for you."

"On the contrary. You had doctors on commercials talking about how cool it was to smoke."

I chuckled. "On the other hand, kids today know of the dangers, and they still smoke. Most kids just think they'll live forever."

"True."

"You probably would have smoked regardless too, hey?"

She smiled. "You know what, you're probably right there."

I've have this type of discussion with a patient from time to time, almost to the point I know exactly what to say; what they want to hear; how far I can push them. Especially when I'm tired at five in the morning I'm not shy about sharing my experiences with my patients, and getting them to share their experiences.

Perhaps we both get some solace out of it.

"Is there anything I can get for you before I leave?"

"No," she said. "But you could take a picture of me as I lie here in this bed and send it to someone who's thinking about smoking. Maybe they'd think twice."

"I doubt they'd think twice,"I said, jokingly

"I doubt it too."

Chronic lungers and fans go hand in hand

When I was a child and having an asthma attack I would open my bedroom window and get instant relief. Sure it wasn't much relief, but it did make me feel a little better. As I grew older I found that I'd have the bedroom window open a lot, even in the middle of winter.

One summer my parents gave me a fan, and I ran that fan every time I was having trouble breathing too, and eventually I learned the soporific drone of the fan was a good sleep aid, and that habit runs to this day, even though my asthma is now under control.

I never thought anything of this, but when I went to RT school I had a classmate who also had asthma, and she too used a fan the same way I always did.

Then when I became an RT I found that many asthmatics and COPD patients have to have that fan blowing in their faces. It's almost to the point whereas when a patient comes in who's SOB I habitually ask them if they want a fan. "Yeah," many say, "I always have one at home."

They also more often than not have the window open and, especially if its humit, the air conditioner on. I've seen this with asthmatics, COPD and CF patients.

In fact, if you go into a room that is ice cold, chances are it will have a chronic lunger it it.

RT Cave #14: If you have a chronic lunger, expect that the room will be cool, a fan will be on, and/or the window will be open. You may find yourself looking around in all the dark ends of the hospital for a fan.

Is this a mere coincidence, or is there some reason people who have experiences being SOB like fans.

I can't remember where I read this, but some magazine about ten years ago had an article about how your face has receptors that are responsive to the wind. When the wind hits these receptors your lungs dilate ever so slightly.

I have never seen any information about this since. However, it would seem to make sense. It's a nice theory of mine I like to share with my patients who "have to have a fan."

More on the agony of end of life issues

A few days ago I presented you, my faithful readers, the end-of-life story of one of my favorite patients. She had led a wonderful life, was terminally ill, was a self declared DNR, had a bad case of aspirtion pneumonia and, as per her families wishes, was set up on comfort measures only.

She was on a non-rebreather to provide her 100% oxygen in order to help her breathing, and she was even on morphine. She felt no pain. However, her breathing was mildly labored.

In my opinion, and the opinion of most people I have had the privilege to discuss this case with the past few days, this was the humane and ethical thing to do in this case. It was time to let nature take its course with this lovely 93 YO lady. It was time for her to go to her maker.

Yet, the doctor provided an option to the family, that he could have the surgeon do a bronch, and that this might buy her some time by cleaning out her lungs. And the family came to the difficult decision to allow the bronch.

So, yada-yada-yada, the surgeon sucked a bunch of brown crap from her lungs, and she was placed on a vent. This is where I left you guys off.

That first night her breathing was SO comfortable on the vent she wouldn't do any breathing on her own. The doctor had conceded she might be a major conundrum to get off this vent. In fact, he said something along the lines that she might be a terminal wean.

But he didn't know I was working.

Without an order I weaned the lady off 10 of PEEP and placed her in CPAP and PS. She did not fail the weaning attempt as I had surmised. After a half hour of the wean I did weaning parameters, and her numbers weren't good by any means, but probably good for her considering her terminal lung status.

Her NIF was only -17. We like it to be at least -20 to consider extubation. Her RSBI was 120, and statistics show 75% of patients with a RSBI under 100 do not get reintubated. Since she was over 100, her odds were not so good. Yet, despite these stats, the Internist on duty wisely decided to give the order to extubate -- after all, she was a DNR.

Now, 24 hours later, she is on BiPAP. She is miserable. She hates the mask. She looks so frail and unhappy. When I go into her room she wants me to hold her hand and talk to her. When I tell her I have to leave, her voice is muffled through the BiPAP mask: "Please, don't leave me alone."

She keeps asking me to take the mask off, but when I do her sats sink fast.

Now the Internist on the case does not want to give her too much morphine as to not knock her drive to breath out. And he doesn't want to put her on 100% oxygen because she is a CO2 retainer.

That ticks me off, considering she was on 100% non-rebreather for five days before she was placed on a vent and she did not stop breathing then. She tolerated the high oxygen quite well as a matter of fact.

Yet now, while her PO2 remains in the 40s, we are allowed to go no higher than 50%. Go figure.

Despite that, I was rather impressed with this doctor. When he was provided an opportunity to yank her tube, he didn't hesitate as some doctors have in similar situations I have experienced.

People, this is a perfect example of why sometimes it is NOT a good idea to take advantage of modern technology. Sometimes it is best just to follow the wishes of the patient, and let nature take it's course.

Are we prolonging life, or delaying death???

What I am going to write about tonight is something we need to have a major discussion about. Because I am convinced there is no solution to this conundrum. It's a conundrum because this terminally ill 93-year-old do not resuscitate (DNR) patient was placed on a ventilator last night.

In talking to her daughter, she led a wonderful life. She never held a job in her life, but her husband had a good job, so she didn't have to work. Instead, she stayed home and took care of the kids.

She has four kids, and all of them became successful in their own right. She was so proud that all her children turned out so well. And she's even more proud of her 12 grandchildren and three great-grandchildren. The flowers all over her room are a testament to how much she was loved.

When she was diagnosed with pulmonary fibrosis (PF) at the age of 88 she decided to make herself a DNR. Yet, even before the PF diagnosis she had become a regular fixture in the hospital with fluid overload, whereas her doctor said to me once, "Even a slight weight gain of 1-2 pounds quite often put her into pulmonary edema."

She was also a lifelong smoker. As a matter of fact, she smoked about a pack of cigarettes a day since the mid 1940s, when she started because it was in fashion to do so. As one of the negative and unexpected consequences of smoking, she has slowly developed emphysema, which has now progressed so that she has become a CO2 retainer.

Considering her grim prognosis, her doctor and family had decided to make her a comfort measures only patient, which justified placing her on a non-rebreather to keep her oxygen levels up despite the fact she was a retainer. But, despite the high levels of oxygen needed, she did not stop breathing (despite what believers in the hypoxic drive theory might contend. but that's a discussion for another day.)

The family had already been informed that their mother probably wouldn't live much longer without getting her lungs cleaned out, and that the best way of doing that was via a bronch. Yet, if the bronch were to be done, their mother more than likely would have to be intubated. But with her extensive medical history, she probably would need to stay on the vent at least over the weekend.

After a brief family conference, the family made the difficult decision to go ahead and allow the surgeon to do the bronch and risk the vent.

While the anaesthesiologist used a minimal amount of sedatives during the procedure, the patients sats consistently stayed low even on 100% FiO2, and the patient was not breathing over the vent when provided the opportunity. So the choice was made to send the patient upstairs to critical care, and to call RT to set up a vent.

As you know, when someone has to go to surgery they wave their right to a ventilator, at least temporarily. Even while a bronch is a simple procedure, it involved placing a tube in her throat, and the doctor peeking around her lungs with a bronchoscope.

As I was setting up the vent, the surgeon told me the right lung was completely filled with pneumonia, and he suctioned copious amounts of thick brown pneumonia not just from the right lung but from the left lung too.

The poor lady. My initial impression was that I'd keep her on the vent a few hours and wait for her to wake up and hopefully extubate her by morning, as I would any other post-op patient. But then I learned the story I just reported to you.

The problem with this case, as the Internist reminded me when he arrived on the scene to manage the ventilator, is that this patient is not weanable. He said, "How do we wean someone off the vent to respect a DNR order when she was on 100% to begin with. I know she's a DNR, but how do we ethically get her off the vent?

This lady was a true medical and ethical conundrum.

Did the family make the right decision? If they did nothing, there mother probably would have died soon. If they did the bronch, it might be possible to resolve the pneumonia, but still, the chance of her ever leading a normal productive life is gone. She is frail and has a terminal illness.

While the family assured me that they perfectly understand modern medicine cannot stop the inevitable, it might buy her some time, "so she can make it to her grandson's wedding in June."

Still, as one of the doctors said to me afterwords, "Are we prolonging life, or delaying death?" That is the question up for debate. What do you think? What would you do?

No Vent, DNR, or full code: what's your choice?

The decision of whether or not you want to be placed on a ventilator, or whether or not you want to make a decision for your loved one, is one of the most difficult decisions one can make. In fact, this is the basis of some very deep ethical discussions, and one of which may never be answered by society, only by the person who has to actually make that decision.

First let us note here that a majority of patients who go on a ventilator do so only for temporary purposes. If you have surgery, if you have severe asthma, pneumonia, or failing heart, you may need to be placed on a ventilator short term.

If a person is involved in a trauma, or if CPR is performed, then a person may be intubated and placed on a ventilator.

Those are easy decisions, especially when we are in emergent situations and are trying to save a life. However, there are also times when the decision to intubate or not to intubate can be complicated as complicated can get, and very stressful, and often disappointing if not discouraging.

In some cases you can plan ahead and write in your advanced directives that you do not want to be placed on a vent, however, sometimes I have seen this declaration over-ruled at the point of impact when a person is in the emergency room and the person has to decide, "Do I want to risk dying now, or do I want to let these good people here in the emergency room help me breathe by placing a tube into my airway and assisting me with my breathing. Do I want to do that? Do I want to allow them to place me on a ventilator?"

Here I will provide some examples for you. All of these come from real life examples as I have actually seen them in my eleven years as a registered respiratory therapist.

One of the most frustrating examples to me is when a person has decided they do not want to be placed on life support because "I don't want to spend the rest of my life on one of those things," or "because I don't want to become a vegetable." In thinking this way, many people choose the following in their advanced directives: Full Code, Do Not Vent, or Do Not Intubate.

I have to cringe when I see that. I cannot believe any lawyer or doctor or advisor would recommend that option, because when a person's heart stops, and we have to do CPR on the patient, we also have to pump in quite a bit of medicine, and 99.9% of the time the patient does not survive a code breathing on his own: he has to be placed on a ventilator. Thus, if we do CPR, we have to put you on a vent -- there is no other option.

What might confuse people is what you see in the movies. There was one episode of "Walker, Texas Ranger," where Chuck Norris's character was having CPR performed on him, and his friend who broke his arm was watching on. Then Chuck woke up, the ambulance arrived, and the person who was taken away on the ambulance was Chuck, but Chuck's friend with the broken arm.

It does not work this way in real life. The majority of the time when CPR is done on a person, that person buys himself a ventilator. That is, unless you are a DNR. In short, DNR means Do Not Rescucitate. That means if your heart stops we will not try to restart it. And, if you stop breathing, we will not place you on a ventilator. We will let nature take its course.

However, if the people working on you don't know you are a DNR, you will end up on a vent regardless. Not only is that the ethical thing to do, it's the law.

However, I do think the decision not to become a vegetable on a vent is a valid issue for most people. Yet, one also has to consider the definition of a vegetable. Are you a vegetable when you have no body, but your brain is fully functional as would be the case with ALS (Lou Gehrig's Disease) or multi-system atrophy, which is a disease my grandma suffered from at the end of her life, and is a disease like ALS in that the person loses control of his muscles and basically becomes a brain without a body.

Some people value life so much that they would want to live so long as they have control of their brain. That was my grandmas wishes, and I totally understood those wishes. However, there is also the issue of depression and humiliation as you are fully aware that you have a tube up every orifice, and some strange person wiping you every time you have a bowel movement. Not only that, but you have to have someone assist you every time you move anywhere. Basically, you are a mind without a body. Do you want to live like that? Do you value life that much? Some people do. And we medical workers respect that.

Then you have the people who have Alzheimer's. These people will have fully functioning bodies but no mind. No mind no matter, no matter no mind. I would imagine that this might be the best way to end your life on a ventilator, if one had to choose between the two. If I were an elderly person diagnosed with Alzheimer's, I would simply make a wish to be a DNR just so that I wouldn't become a ward of the state, a useless blob of skin on a bed taking up space and absorbing taxpayers money. However that would be my decision, I have to respect the wishes of others who think otherwise. Thus, life is very precious no matter how fragile, and each individual has to decide for himself.

Then, let us consider the COPD patient who decides that he does not want to be placed on a ventilator. He is not necessarily end stage, but he is to the point that he cannot go without using his oxygen. However, he has a quality life to the extent that he is not one of those people who simply sits around and feels sorry for himself. He loves life. He loves living. However, he was also scared by the prospect that he might be placed on a ventilator and have to stay on it the rest of his life. So he makes the decision one day that he will make himself a d0 not vent patient.

Then one day he is having trouble breathing. His wife drives him to the hospital and by the time he arrives there he is severely short-of-breath; his work of breathing is labored. The doctor looks the patient straight in the eyes and asked the question no one wants to ever hear, "If something happens to you, do you want to be placed on a ventilator?"

Of course now the patient is not in the planning stages. He is actually miserable, gasping for every breath. His oxygen levels are falling. His CO2 levels are rising. He is pooping out. He has a feeling of impending doom. He, however, does not want to die; he is not quite ready.

Then again, he does not want to go on one of those things; he does not want to be intubated. So, he asks the naive question that is really not so naive because the only people who truly know the answer were standing in the bright room around him. Of course there were other COPD patients who knew the answer, but they were not in the room. His life, his destiny, was in the hands of the fine medical workers in the room.

"So," he says, huffing and puffing, barely able to get the words out, "How long would I have to be intubated for?"

"Well, the goal would be a day or two, but we really can't guarantee," the doctor explains.

Of course she doesn't want to give false hope, but she also doesn't want the patient to simply give up hope at the same time. This is the ironic twist that we often face in the emergency room. "The goal is basically to rest your lungs and allow them a chance to heal. That's the goal. I can't guarantee anything, but that's the goal."

I stand there thinking, as I am getting my intubation equipment ready just in case the patient makes the decision, that the doctor made a good presentation. In fact, I couldn't have worded it better myself. The key words there were "help you get over the hump" and "I can't guarantee anything."

By these short phrases the doctor threw the ball completely in the patient's corner. And, if the patient were to pass out, into the wife's corner. And if the wife were not there, the medical staff would have no choice but to make the patient a full code and do everything for the patient, unless they were 100% positive the patient was a DNR.

Another case I've seen is the elderly man with a chronically failing heart come into the hospital in respiratory failure secondary to the failing heart. The patient is non-responsive, and he is also not a declared DNR. The wife now is forced to make the decision of whether or not to allow nature to take its course, or to allow the medical staff to intubate her husband and place him on a vent.

"What should I do?" the patient's wife asks the Doctor.

"Well," the doctor says, "I know this is a difficult decision. Since you are in a very stressful situation right now and you want to make sure you don't make the wrong decision, perhaps it would be best to let us intubate your dad, and you can see how things progress, allowing yourself some time to spend with your family and to think, and then in 24 hours you can see how things are going with your dad. Either way, I can't make any promises. It's your decision.

The doctor pauses, allowing the patient time to think, before continueing. "Technically speaking, the goal of going on a vent is short term therapy to allow your husband's heart and lungs to rest. If things work out, he might come off in a day or two. However, I can't honestly say those odds are very likely right now. But, if things don't work out, he very well could be dependent, that's always a possibility. But if it comes to that, you can make a decision to terminate the vent if you wish."

After another pause, the doctor solemly states, "However, if he doesn't go on a vent now, there is very little chance he will survive this."

In this case, the wife decided to place her husband on the vent and the patient came off two days later with full mental capacity. Of course he was limited in what he could do, and had to go home with oxygen. And while his heart remained severely fragile, he was able to spend another two years.

Thus going on a vent "to get over the hump" bought this man two years to say good-bye to those he loved, and allowed those he loved to say good-bye to him.

I talked to the wife a year after he died, she told me she was very pleased with her decision to place her husband on the vent.

One time we had a lady on a ventilator with ARDS, and as she was on the vent for the fourth week, it was becoming evident that she wasn't going to make it. The patient had already been given a slim 10-20% chance of surviving by the doctor.

But the family stood firm with their hope, and prayed the patient would not only come off the vent but have some quality of life thereafter. Even the family was starting to give up hope after a while, though. Then one day, as though by some miracle, the patient woke up and was eventually discharged.

I know that's a rare instance, but patients with grim chances of survival can survive. And while it might be fine to say, "I've seen people like this survive before," you still don't want to give a family member false hope.

Likewise, I have seen many cases similar to my above examples go in different directions. In the medical field, you just never know what's going to happen. And, when you are making end of life decisions, you never know what the right answer is.

There are times, though, where I would definitely recommend a DNR status. These would be elderly people over 90, and any person who has a terminal end stage illness. If you have an 80 year old lady dying of cancer, it would be kind of foolish to place that person on a vent, when all the vent would do is delay the inevitable, and cost the family insurance and taxpayers thousands of dollars in the process.

Yet, I see these people going on ventilators all the time. In many cases it becomes quite frustrating to see these people on the vent for weeks on end. And, this can quite possibly be one of the most frustrating parts of the medical field. Sometimes I even feel sorry for these people, especially when it appears to me they are trying to die, and their family members keep pushing for them to live.

Recently I placed a cerebral palsy patient on a ventilator. He is off now and back at home in the care of his family. The quality of life for this person was already pretty low, but the family loved this young man and truly valued the sanctity of life. We had to respect those wishes, and we took care of him as we would any other patient.

So, if you are wondering whether or not you want to be a full code or DNR should your heart stop, or whether or not you want to go on a ventilator should you stop breathing (and many times those two come together in the same package), you should take some time to consider the what ifs.

It might be a difficult thing to stop and think about, but it could save you and/or your family members a ton of stress in the end.

As you can see, this is not an easy subject matter for anyone, including us in the medical field. And this has been and will continue to be an important ethical discussion for years to come.

What's it like to be intubated?

As I was looking at my blog statistics, and checking the recent keyword activity that landed someone on my site, I noticed one person had typed in the query, "What's it like to be intubated."

I remember waking up from a surgery once, and this person pulling something out of my mouth. I had no idea until I went to RT school what had actually transpired at that moment: I was being extubated.

So because I was medicated, I had no memory of being intubated, and had no memory of my time on the vent during the surgery. Thankfully, I must add, I have no memory.

Fortunately, I think that is the case for most people who are intubated. I think that we keep them sedated enough that they do not remember much. However, on occasion, we do have to intubate people under emergency situations where there is no time to medicate the person, and usually that person gags and groans during the process. There is no doubting the this is not a pleasant procedure to have done.

Which is why Succiconine is such a great drug, because it paralyzes a person just long enough to get the job done. And then, while the patient is serving time with a ventilator doing all the breathing or assisting with it, a patient is sedated enough with some good meds to allow the person to rest comfortably. And, while the patient is often awake, the meds are good at causing amnesia.

Lots of times I have to communicate with a person on a vent. Of course they can't talk, but you get pretty accustomed to lip reading after a while. Then, a few days after the patient is over the hump and is extubated, you ask them if they remember being on the vent, and they will tell you they have no memory of it. That's not always the case, but most of the time it is.

Occasionally, a patient remembers everything. Some patients are awake, alert and orientated the entire time they are on a vent. It's these people where you can learn the most from of what it's really like to be intubated.

It doesn't always suck either. I remember this one chronic end-stage COPD patient who was extremely short-of-breath. She told me she felt like she was suffocating. The next time I saw her she was on a vent, and she looked at me with eyes of joy. She smiled. She took in a deep comfortable breath. That vent was her savior.

That patient did not want to get off that vent.

I like to explain to my vent patients, if they are at all comprehensive, that they have not been placed on a ventilator permanently, it's just short term until their lungs get better. It's more or less to allow their bodies time to get over the hump. That's the case most of the time. And, usually, the person is off the vent in a day or two.

While I can honestly say that I have experienced much of the things I do for patients on a daily basis, I have never been on a vent; and I have never been suctioned.

One of my co-workers and good friends and fellow asthmatic was placed on a vent once, and she said she remembers the whole thing. She remembers being awake and alert and looking out the window and seeing a Burger King, which sucked because she was starving. And, she said, that wasn't even the worse part. The worse part was getting suctioned. She said there is absolutely nothing worse than that.

That in mind, a fellow blogger who used to be an RT, and who is unfortunately a victim of severe persistent asthma, was placed on a ventilator recently. I thought his story was very inspiring, and I would like to link you to his blog: The Bay City Walker.

The hypoxic drive theory: reality or simply a hoax?

(This is part one of a six post series. To view entire series click here. )

One of the theories that evolved as the field of respiratory therapy evolved was the THEORY of the hypoxic drive. That is where if a patients oxygen level gets low enough, a patient's brain will signal the patient to breathe.

While CO2 is usually what causes people to breathe, when the levels of CO2 is chronically high, particularly in patients with chronic bronchitis who have developed a chronically elevated CO2 level "that cannot be lowered significantly regardless of patient effort," according to Egan, Fundamentals of Respiratory care, (page 336 volume 6, 1995), CO2 no longer effects a patients drive to breathe, and low levels of oxygen (hypoxemia) "drives ventilation quite strongly."

Due to this theory, it is recommended that people who are CO2 retainers not be placed on oxygen greater than what is absolutely necessary. Generally, the accepted wisdom is that a PO2 level of 50-60 torr is the target PO2 we reach for with these patients, which is equivalent to an SpO2 of 80 to 90%.

And, if a patient is given too much oxygen, the theory suggests, this patient will lose his drive to breathe, his CO2 becomes much higher, he ultimately becomes lethargic, and will at some point stop breathing. Therefore, we medical workers in charge of the patient want to avoid using FiO2s greater than 40% for the most part.

However, also according to Egan, (page 707, volume 6, 1995) while hypoventilation is a hazard of oxygen therapy, "this harmful effect should never stop us from giving oxygen to a patient in need. Preventing hypoxia should always be the first priority."

So far I've stated the obvious that all of you wise RTs already know, but what happens if you have a chronic CO2 retainer patient on 100% oxygen to maintain a PO2 of 40%? Will that patient lose his drive to breathe?

In my professional experience, I have seen maybe two patients who became lethargic when the oxygen was turned up, but I have also seen many patients in this situation be placed on a 60% or greater FiO2s and never have his drive to breathe suppressed.

The point of this post is this: Is the hypoxic drive theory a hoax?

As I reported in a previous post, I accidentally mentioned that I am not necessarily a fan of the hypoxic drive theory to an RT student. I did not go into detail as I caught myself. However, the following week she told me she "in passing" mentioned this to her teacher, who said, "What are they filling your head with?"

Yes, it is true that we have to be careful what we tell our RT students, but at the same time we want them to be aware that what they learn in school is not exactly the same as what occurs in real life here at the hospital. And, the truth to the matter is, the hypoxic drive theory is just a THEORY.

In the next few weeks I will review briefly why people breathe, and then I will share some information I have that challenges the hypoxic drive theory. My goal here is not to convince you that the hypoxic drive theory is a hoax, but to inform you of other theories out there that might more accurately describe your patient's condition.

Stay tuned.

WARNING: As I stated earlier, the hypoxic drive theory is the gold standard theory of respiratory care. Most doctors live by it. If a doctor says lower the oxygen level on a patient because he is a CO2 retainer, it is your job to do what he says, even though you have proof that a) the patient is not a retainer, and b) the patient is a retainer and the oxygen is not harming the paitent. You may try to convince him otherwise, and he may also grumble and gripe.

WARNING #2: Since the hypoxic drive theory is the gold standard of respiratory care, it is strongly defended by RT teachers. And therefore, for you RT students out there reading this, know that any material opposing the theory will more than likely not be on your RT exam.

Xoponex may soon rival Albuterol in cost

Apparently, Medicare has decided to list Xoponex under the same reimbursement codes as Albuterol, meaning the cost of Xoponex may drop as much as 70-80%. This could mean a lot for any person in need of a rescue drug, because it will provide doctors, RTs and patients with more options.

Of course this decision could be reversed, but if not, it could provide another cost effective option in the care of patients with COPD and asthma. Some studies have shown that patients given Xoponex in the hospital got better faster, other more recent studies show that Xoponex works no better than Albuterol.

And, while some studies initially showed that Xoponex has fewer side effects than Albuterol, more recent studies show otherwise. These new study results may or may not have had an effect on the Medicare boards decision.

Either way, doctors at Shoreline have been instructed to stop using Xoponex as a front line bronchodilator based on the more recent studies. For more information, check out this article.

Personally, based on my experience with Xoponex, I don't think it's worth the added cost. However, if the cost of Xoponex is going to be the same as Albuterol, doctors, RTs, hospitals and, most important, patients will be able to try both meds to see which one works best for them.

Some basic facts about COPD you should know

Perhaps secondary to pneumonia, the second most common type of patients I see on my respiratory therapy treatment sheet are COPD patients. In fact, I've seen so many of these patients I can recognize them by mere sight.

COPD is going to be the focus of this blog for the next month or so. I'm going to be analyzing this disease to provide me and my fellow RTs a nice refresher course, but to better educate my COPD audience as well. The more we RTs know, the better we can benefit our patients, and the more our patients know, the greater likelihood they will avoid having to come in to see us RTs.

I always say when I'm leaving a room knowing that the patient is going to be discharged later that day, "Well, the next time I see you it will be at a grocery store or a restaurant." Then they laugh. And they laugh with me two weeks later when I actually do meet them in a restaurant and barely recognize them because they are wearing street clothes.

But, far too often, we meet again in one of our hospital suites. Sometimes it's only a week or two after they were discharged, and the lucky ones I don't see for another year or so. Either way, the more they know, and the more I know to educate them with, the better off they are, and the more likelihood they can avoid visiting me again.

However, aside from being well educated, they also have to be compliant, or else no amount of education will do any good.

You can look up the definition of COPD via the various links on this blog if you want to. I'm not going to go into detail on that, at least not yet. What I'm going to delve into is deeper than what will be covered on most COPD websites.

I've decided that this week I would simply relay some basic facts regarding COPD that I've obtained via various sources:

1. COPD is the 4th leading cause of death worldwide, yet 75% of those affected remain untreated. It is also the 4th leading cause of death in the U.S.
2. The World Health Organisation estimates 600 million people worldwide have COPD.


3. COPD is projected to be the third leading cause of death by 2020 with only heart disease and cerebrovascular disease accounting for more deaths.


4. Higher prevalence rates for COPD are found in men than in women globally reflecting historic gender differences in smoking behaviour.


5. Prevalence figures for COPD are believed to be underestimated. Sufferers tend not to seek medical advice until the disease has progressed and the condition is severe. Or, in other words, an estimated 30 million Americans have COPD, while only 16 million adult Americans have been diagnosed with disease.[


6. Quality of life is severely affected in patients with COPD, with 80% of patients hospitalised following an exacerbation reporting a health status rated or quoted by a physician as being 'worse than death'.


7. Lost productivity due to COPD can have a devastating effect on the economy, and the greatest emphasis of medical professionals is to improve the quality of life for COPD patients so they can be productive members of society.


8. COPD has a higher mortality rate than asthma (5,438 deaths from asthma in 1998 versus 107,000 deaths from COPD in 1998).)


9. The highest increase in mortality has been in white women, as observed between 1960 and 1998.


10. In 2000, the annual cost to the nation for COPD was estimated to be approximately $30.4 billion. Health care expenditures accounted for $14.7 billion, and indirect costs (decreased income due to loss of work or premature death) were $15.7 billion.


11. In a recent survey, 7 out of 10 smokers could not identify COPD as a top-five killer.


12. In 2002, about 125,000 people died of COPD.


13. While other chronic health diseases such as heart disease and diabetes have decreased in the past 20 years, COPD rates have steadily increased.


14. In a recent survey 66% of Americans did not know that COPD kills more women than men.


15. Women who smoke are more susceptible to developing COPD than are men.


16. Women may develop COPD at an earlier age and with less duration or intensity of smoking


17. U.S. women had more COPD hospitalizations (404,000) than men (322,000) and also had more emergency department visits (898,000) than men (551,000) in 2000.


18. More women than men die of COPD.


19. Cigarette smoking is the leading cause of COPD


20. Breathing in second hand smoke can cause COPD (in fact, I witnessed this with my grandma.)


21. Working around certain kinds of chemicals and breathing in the fumes for many years can cause COPD.


22. Working in a dusty area for many years, air pollution can cause COPD


23. Having a history of frequent childhood lung infections can cause COPD


24. Alpha 1 Antitrypsin Deficiency can cause COPD

Next week I'll focus on ways COPD sufferers can avoid a trip to the ER and live a more productive life. I'll provide some real life examples form my experiences.

Resources: AARP, COPD Coalition, yourlunghealth.org,

Some good asthma/COPD drugs get a bad rap

When I was researching Singulair, I found an article here on the Internet about how Singulair may be linked to depression and suicide thoughts. There were so many complaints of this, that the company that makes Singulair decided to put this as a side-effect on the insert.

You can check out a related link here from Allergy notes, or click here for a full article from Forbes.com.

The same thing happened a few years ago about Serevent. There have been people who have died after taking Serevent. It became so bad that there was talk of actually taking the medicine off the market.

Needless to say, I disregarded both these scares, and now I take both Serevent and Singulair, and neither do I suffer from depression, I also have not died -- at least not yet.

People die of asthma. And it just so happened that in a majority of the cases where an asthmatic has died in recent years, the person was taking Serevent. So some people came to the conclusion that Serevent was a bad med and should be taken off the market, and released statements (like this one, or this one) that scared people.

Yet, as it turned out, there really was nothing wrong with Serevent. Serevent is a good medicine that helps asthmatics better control their asthma. Yet some people decided to abuse Serevent, use it like it were a rescue inhaler instead of one puff twice a day. More than likely, the abuse of Serevent caused the heart to become overstimulated, and the asthmatic dies.

However, and thankfully, the powers that be decided the problem was not so much with Serevent, but with people abusing an otherwise good medicine.

For the record, here is a link to what all doctors should tell their patients about Serevent: click here.

National Jewish makes light of the fears of using Serevent on its website, and in its effort to make sure its patients are fully educated, issued the following statement:

"In a large asthma study, more patients who used Salmeterol died from asthma problems compared to patients who did not use salmeterol. This has received much attention in newspapers and magazines. While the relationship between Serevent® and deaths due to asthma remains unclear, proper use of this medicine can decrease any risks"

To read the rest what National Jewish has to say about Serevent, click here.

The company that makes Singulair, and doctors, have issued statements to their patients that if a patient is currently taking the medicine, and have not had a problem, then they should continue to take it as they have -- as prescribed. If they have a problem, if they have symptoms that are new since they started taking the med, they should stop taking it and talk with their doctor.

That's common sense there, but for PR and legal purposes it has to be said. Likewise, it's something doctors should do anyway -- or at least the pharmacist. Personally, I have never had a doctor go over with me how to use a medicine, or possible side effects. That seems to be a job reserved for RTs and RNs.

But, what if a patient doesn't have contact with an RT or RN? How do these people get proper education on the medicines they take?