Ventolin does not prevent asthma -- my opinion

When I was 15 and a patient at National Jewish in Denver, all of us asthmatic kids were forced to take 2 hits off a Ventolin inhaler prior to working out.

"Why do this now, when I'm going to need it as soon as I finish working out," I said once. My gym instructor made me run an extra lap for my mouth. So I learned not to speak up, regardless of my opinion.

Still, as soon as I was done with an aerobic session, I found that I needed a little hit of Ventolin regardless of the pre-workout dose. Not always, but there was still that bit of tightness after working out.

In retrospect, I think that even 18 years ago, long before I would even think of entering RT school, I was questioning doctor orders. Still to this day I do not think that Ventolin is a preventative medicine, but it's still ordered that way.

Why else do you think doctors order it QID on COPD patients who show no signs of being short-of-breath, or TID or even Q4 for that matter. At least in the hospital, I see no need to order Preventolin. A steady dose of Allbetterol might work better for some of the sick patients we have, but not Preventolin.

The other morning I had to give a treatment of Ventolin 30 minutes prior to a stress test. This was on a lady who had a history of asthma, but has not had a problem this visit. If she's SOB I see no problem with this, but not just because.

"Well, she has exercise induced asthma," my RT co-worker said.

"So, that's not a preventative medicine."

Is it? I have heard this talk all my life, but on me personally, taking a hit of Ventolin has never prevented asthma. There are other more appropriate medicines that can work preventatively, like Flovent, Atrovent, Singulair, Advair, Azmacort, Spiriva. These are medicines made to help prevent asthma. Ventolin does not prevent.

I have talked to an Internist of whom I really respect, and I asked her if we could DC the treatments that were ordered QID on a COPD patient who had been on treatments for two weeks, but never indicated any signs of SOB.

She said, "NO. We need to keep the Ventolin in his system to prevent an attack. You know that!" She looked at me like I was a dufass.

Oh well. That's all I can do is state my opinion. I have that right. I have a right to my opinion, I have a right to be wrong. I have a right to be stupid. We all have a right to form opinions, as have all the doctors and nurses.

It's one of the better parts of living in America.

Again, I have had asthma almost my entire life. I have been using Bronchodilators off and on since I was about five, have had my own inhaler to abuse since I was 10 (Alupent), have had a prescription to Ventolin since 1991, and have never noticed Preventolin (that's what I call Ventolin when it's used to prevent asthma) ever having an effect on me.

If I was going to have an exercise induced asthma attack, it's going to happen regardless of whether I take a hit of Preventolin. In fact, that's why I take Advair and Singulair, to prevent me from having problems while running. And I do run (okay, since you want to be technical, I jog) 2.5 miles every other day without having asthma, and without using Preventolin. I also do not use Ventolin after I work out.

I've never noticed it to prevent anything. I do notice it treats bronchospasm, but that's old school now I guess. Now that Ventolin comes packaged and marketed as the next coming of holy water, it seems to have unlimited uses.

For more uses for Ventolin, check out my list of 'olins at the bottom of this blog. Of course this is all in good fun, and it's all at the expense of stupid doctor orders -- my humble opinion of course.

Please feel free to agree or disagree with a comment.

My Dr. now prescribing Singulair for allergies

My Internist and I had a neat little conversation about medical fallacies yesterday. He assured me that it isn't just RTs who get irritated with people getting all excited over "one" study.

I wrote here last December how I was hospitalized with a bleeding ulcer. My Internist wasn't the one who took care of me then, and he asked me if the surgeon who managed my care ever determined the etiology of my ulcer.

"Well," I said, "At first he said there was a 90% chance it was caused by H. Pylori, then he said the test came back negative. But I think I had H. Pylori, because I could have sworn when I looked at my chart the test was positive."

"I guess it really doesn't matter," he said.

"Why do you say that?"

"I think the H. Pylori thing causing ulcers is over hyped." Then he rattled of some facts so fast they rolled right over my head.

"How do you think I got the ulcer then?"

"Nobody really knows for sure. It's just since many people have H. Pylori, some people say that is what causes ulcers. The truth is, they really don't know. So the pharmacy company has us doctors treating the H. Pylori, and all it does is run up the medical bill."

I wanted to say, "Kind of like Ventolin." But I held my tongue.

Later I told him how miserable I was last spring with allergies. "I decided I can't suffer like that again," I said. "This year, since you started me on Singulair, it's almost amazing the difference. It's almost like I don't have asthma."

You must note here that when I mentioned to him last Jan. that I should try Singulari, he told me he thought that drug was overhyped. In May I told him how wonderful the medicine was working for me.

He said, "I just started a new person on Singulair today based on your testimony last time you were here."

"Cool," I said, "I have heard some bad things about it, though."

"Really, like what."

"Well, one kid was having suicidal thoughts, so now they blame it on Sinulair. Like you say though, I think it's all overblown."

"Yeah, I've heard that too now that you mention it."

"So now you have a lot of moms taking their kids off Singulair based on the this, and it's very unfortunate. My childhood sucked because I had allergies so bad, and my doctor wouldn't even let me have anithystamines because on the box it said not to take it if you have asthma. Now they have this new drug that will allow these kids to live normal lives, and parents and doctors won't let their kids take it based on a fallacy. It's a shame."

"I agree."

"So, anyway, my allergies are basically non-existent right now, and I give Singulair credit. Of course it could be a coincidence, so I'm still open minded. But it seems to be working great."

"Cool."

"I kind of joke about it though. I tell everybody that since I started on Singulair I don't have allergy problems anymore, but I have suicide thought."

"Yeah," he laughed, "If your allergies come back you'll kill yourself."

There's some truth to that, too. I can understand how allergies can get so bad sometimes, that you might rather be dead. There were times when I was a kid, and even as recently as last summer, where the allergies were just unbearable. (Not that I would ever kill myself, I'm just saying that allergies can acuse severe misery).

Singulair is a great medicine. It has worked a miracle for this RT. I think all asthmatics should at least try it if nothing else works, it beats the alternative of being miserable all the time.

Another bad thing about Singulari is it is expensive because it is still under patent.

Related articles: Some drugs get a bad rap, and Singulair: Another asthma miracle drug.

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.

High & low humidity both bad for asthma

I remember when I was a kid -- like say 10-years-old or so -- and having an asthma attack, and my dad taking me into a bathroom that was full of hot steam. Sometimes he'd have me sit in there for what seemed like a long, long time.

It never worked. In fact, every time I remember my dad doing this with me -- every time in the middle of the night -- I ended up in the emergency room anyway. I do remember feeling more refreshed when I walked out of the bathroom, but I was still short-of-breath.

I also have vague memories of a humidifier in my bedroom. My mom would set that up whether I was having a bout of asthma or not. Despite her efforts to set this up, it never seemed to do anything for my breathing. If asthma was going to occur, it was going to occur.

My parents did this because they were told by my pediatrician that humidity was good for breathing. It was common knowledge back then for doctors to recommend humidity for asthma.

I was discussing this with Jane Sage today, and she said she used to set up ice tents on asthma children routinely. She said scientists and doctors honestly believed they were doing something to help asthmatics.

It was a fallacy. We know that now. Steam works well for inflammation of the upper airway, or croup, but it does not work for asthma.

Many times a mom woke up because her child had a harsh barky cough, or croupy (stridor) expiration, and the child was working hard to breath as a result. A trip to the bathroom usually
worked wonders, and prevented many trips to the hospital. Steam can be soothing to the upper airway.

Cool mists work well for croup too, but not for asthma. If the mom of the croupy child decides to come to the hospital, and it's the middle of winter or a rainy day, the child is usually cured even before she arrives at the hospital.

And, if this croupy child did get admitted, he would be placed either in a cool mist tent or set up with a cool mist aerosol. Now we just use a cool mist aerosol in stead of the tent.

But this therapy seldom works for asthma. In fact, steam, or cool mist tents, or aerosols, have a tendency to make asthma worse. It makes the air thicker, and the patient has a more difficult time inhaling it in.

Still, I have asthma mom's and asthma dad's ask me on a regular basis if they should set up humidifiers for their asthma children, and each time I have to correct the old fallacy that humidity is good for asthma.

That in mind, allow me to introduce you to RT Cave Rule #19:

RT Cave Rule #19: Humidity or cool mists may work wonders for croup, but can make the air difficult to breath for asthmatics. In the hospital, cool mist therapy can be used for croup patients, but not for asthma.

And this is one of the reasons that dehumidifiers and air conditioners can be of benefit for asthmatics (and COPD patients) because they remove the humidity from the air and make it lighter and, thus, easier to breath.

This is my opinion of course. As you will read in a moment, there has been much scientific research on humidity and asthma.

According to Sue Hare and Joe Buchdahl, co-coordinators of the Atmosphere,Climate and Environment Information Programme (see article here, or related article here), areas on the planet that had a relative humidity lower than 50% had fewer "rates of asthma." This problem may be exacerbated in big cities, "because the urban 'heat island' effect caused by asphalt and concrete trapping heat at night."

The report also states that "for every 10% increase in indoor humidity was associated with a 2.7% increase in the prevalence of asthma."

While they may not have had access to these expensive studies, this is also one of the reasons why asthmatics, like Teddy Roosevelt for example, used to report finding relief moving to areas like Arizona where the air is dry all the time.

However, moving to Arizona is no longer recommended, as the increased levels of smog may offset the benefits of the dry air.

Now we have plenty of scientific evidence to support the claim that dry air is better for asthma.

Scientists, according to American Academy of Allergy, Asthma and Immunology (aaaai.org), have determined that high humidity levels have a tendency to be harboring grounds for fungus and molds that might bother asthmatics. Plus, when the humidity is greater than 50%, the amount of dust mites in the air is increased. For this reason alone, humidity is no longer recommended for asthmatics by pediatricians.

Likewise, if you have ever been in a hospital, you probably noticed how dry it is in these places. Noses get dry, hands get chapped and start to crack (especially in the winter months). The reason is because the humidity of hospitals is kept low as to not create a harboring ground for fungus, molds and dust mites.

That's also why the air is cranked up in the summer months too. Sure, you may be cold, but this is good for disease control, and great for asthmatics.

As per The American Lung association, "Air-conditioning can help. It allows windows and doors to stay closed. This keeps some pollen and mold spores outside. It also lowers indoor humidity. Low humidity helps to control mold and dust mites."

On the other hand, also according to aaaai.org, if the relative humidity is less than 15%, this may trigger an excessive cough for asthmatics. Thus, it is recommended for "asthmatic patients to aim for a 'happy medium' relative humidity in their homes, monitoring their home humidity regularly with a reliable gauge."

The Center for Disease Control and Prevention recommends humidity be set between 35% and 50%.

I suppose you could use a convenient humidity monitor (like this). (I am not endorsing this product, I just coincidentally found it while doing my research tonight. In fact, I didn't even know it existed until a few moments ago.)

Personally, I do not have an air conditioner at home, nor do I control my humidity, but often times in the dog days of summer I wish I could afford it.

Likewise, working in the nice cool, clean air environment of a hospital was one of the best incentives of me deciding to be an RT.

(Allergy Be Gone has an excellent related article. This is also where I got that cool picture from.)

New Breakthrough in asthma, COPD research

It seems scientists are making some breakthroughs in the study of asthma and COPD.

Over at COPD Alert, someone posted about how researchers at Washington University School of Medicine in St. Louis linked asthma and COPD to a new type of immune response "that is activated in patients with COPD and severe asthma."

Click here for a link to the article.

Scientists say "their discovery could dramatically improve diagnosis and treatment of patients with chronic inflammatory lung disease...With this information, we can more precisely diagnose and monitor these types of diseases and then better target our treatment to specific abnormalities. That's a big step forward from simply monitoring breathing status."

Basically, this new theory proposes that asthma and COPD are basically a chronic immune response triggered by a respiratory viral infection.

While the cause of asthma has alluded scientists, this research may lead them in the direction of finding a cure.

This topic came up in the comments section of my blog and Amy's blog, and my most recent response became so long I decided just to turn it into a post.

Here's the deal. There is this "really cute cat" down the street from us, and it is "free."

My wife is trying to convince me that Singulair should prevent an asthma flair. Plus, she read somewhere that most people aren't allergic to cats per se, but to their saliva. Cats lick themselves to clean themselves, and that causes the allergic response. So, as per her source, if you wash the cat daily, you shouldn't have a problem with allergies.

Now, the gamble is, once you have a pet in your house, it walks the whole house, and if you do find out you are allergic to it, there's no way you will ever get all of the allergen out of your house. It will be there forever.

That's the argument I hang to when the subject "CAT" comes up. Now she has my 5 YO winking her cute little eyes at me saying, "Please, dadda, please..." It's not easy saying no to that.

(Ironically, I wrote about cats on my other blog just yesterday. Go figure.)

On a side note, we haven't done so well with pets in the past. When we first got married we simply "had to" get a dog. Mind you, I love dogs, but when you live in town, a barking dog can cause a lot of stress for an owner, especially when the neighbors keep calling the police.

But that wasn't the half of it. We had a fenced in yard, and we thought that would suffice. But the dog learned that it could dig a whole under the fence, and roam the town, causing havoc with other dogs. After the police gave me a ticket for this, I had no choice but to find a new loving home for this dog, even though I really liked it other than these two things. I even taught it to walk on two legs.

We "had to" get a hamster once too. But it somehow kept getting out of its cage. About the fourth time this happened I realized that my boy, then four, was opening up the cage every time he went to the bathroom alone.

Well, one day the hamster didn't look so good. We figured it got into the rat poison in the basement. No more hamsters.

We had fish too, but for the life of me (no pun intended), I could not keep fish alive either.

Thank God we are better at raising humans than raising pets.

So, now "we just have to" have a cat.

I'm not allergic to dogs or hamsters, and even though cats don't bother me, the test did show a positive result for cats. So, I'm sticking to that argument.

However, my wife and both my kids ask me at least 20 times a day. All it takes is one weak moment, so their strategy might pay off.

Besides, how can a dad say no to the little girl in the pic.

"Daddy, please..."

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."

Warning: second hand smoke is harmful to kids

The sign said, "Kid Zone: NO SMOKING."

Yet the smell of smoke wafted through the air around me. I turned around and saw 30ish year old man smoking in his car, two toddlers jumping around in the backseat, and a mom leaning on the hood of the car holding a baby, who happens to be sniffling and coughing.

I move myself and my little girl so we are now standing on the other side of the soccer field, yet the wind is still blowing the smoke our way. I turn around and watch as the scruffy faced dad tosses his cigarette butt out the window, apparently unaware of the fact he is littering.

I breathe in fresh, non-smoke filled air. It feels good. I figure we should have clean air from here on out. And, just as my daughter runs off amid the crowd of spectators, I smell smoke again. I do not turn around this time, though, because my son has the soccer ball and he's....

These people are so ignorant they can't even not smoke for one hour during a kid's soccer game. I wanted so bad to get up and tell this person to stop smoking. I never did, and neither did any of the other parents. I wondered if they were as annoyed by it as I was. I never asked.

I wanted to tell this person that I think it's fine that he chooses to put arsenic, acetic acid, acetone, ammonia, benzene, butane, carbon monozide, ethanol, formaldehyde, hydrazine, hexamine, hydrogen cyanide, lead, methane, mathanol, napthalene, nickel, nicotine, phenol, polonium, stearic acid, styrene, tar and toluene and 3,580 other substances into his body -- the contents of one cigarette.

But why make all these kids ingest these same toxins, which are poisons likely to cause cancer in humans, or cause one of the kids to have a flair up of asthma? Hey, second hand smoke is even known to cause asthma.

But that doesn't matter though, cause that guy is enjoying his cig.

After watching the game for a while, I notice I STILL smell smoke. Gosh darn it, I thought that cig would be gone by now. But no, he keeps lighting 'em up one after another. And then I notice the mom is no longer standing outside the car, she is inside with her smoker of a boyfriend. She has now joined him in smoking.

I was rather irritated. I thought again that I should go up to the open car window and tell that mom that a recent study found that infants are three times more likely to die from SIDS if their mother smoked during and after pregnancy. Also, infants are twice as likely to die from SIDS if their mother stopped smoking during pregnancy, and then started smoking again after birth.

I'm sure she wouldn't care, though. She'd probably just be annoyed that I was rude to annoy her.

That chronic cough, wheezing and excess phlegm your baby is coughing up is probably because of you, I wanted to say. And all your kids are very likely now, because of your ignorance and irresponsibility, to have a reduced lung function as they grow older, making them more susceptible to chronic lung and heart diseases, and therefore probably shortening their lives.

She would tell me I was just making this up to scare her. I'd tell her the facts, that 150,000 to 300,000 kids develop lower respiratory tract infections like pneumonia and bronchitis each year in children under 18 months of age.

When your baby develops bronchitis, you will get to know me very well, as statistics show that 7,500 to 15,000 of these children are hospitalized each year. If your child is the exception, it's only because you are lucky. Are you willing to play the odds game with your kids?

I suppose it doesn't matter so long as you are enjoying yourself. After all, it's all about you anyway.

I don't know if it's because I'm an asthmatic, have an asthmatic daughter, care about other people's kids as well as my own, or the health of my pregnant wife, or the fact that I'm an RT, that it bothers me so much that that guy continues to smoke and smoke and smoke and smoke some more in the span of a one hour kid's soccer game in the Kids Zone.

Yep, that guy and that mom have a God given right to do what they want in this life, but why they insist on endangering the lives of their children, let alone mine and all these other innocent kids running around this Kid Zone, I will never understand.

"Hey, there's a sign right there, can't you read it."

It's not just soccer but other kid events too that this happens. Last summer at baseball games I came across this same situation. There is always one jack-ass in the crowd who naively sits in his lawn chair puffing away, forcing everyone in his or her vicinity to breath in the second hand smoke.

Is it fair that I should have to keep getting up to move away from someone else's exhaled smoke? Or should I break the silence and become the bad guy who tells this smoker to put it out.

It's kind of ironic, isn't it, that I would consider myself the bad guy here, when the true bad guy is the one holding the cancer stick. Or am I wrong here?

Note: All the information and statistics provided in this post are compliments of a packet called "Michigan Smoker's Quit Kit," which was written by the Michigan Department of Community Health, 2006.

Stop smoking in front of your kids. Period.

Here's another issue that could be discussed in ethics class at some lengths. Or, better yet, a great topic for Stupid People 101. What do stupid people do? Stupid people smoke in front of their kids, that's what they do.

I'm so sick and tired of taking care of kids because their parents are too stupid to know better. Kids do not know any better, and therefore it is the responsibility of parents to create a safe, clean and healthy environment for their kids.

Smoking in front of your kids is not safe, clean nor healthy. In fact, it is just plane stupid and irresponsible. It may have been acceptable 50 years ago because people didn't know any better, but there is so much information out there, there are no more excuses for this kind of stupidity and ignorance.

The fact is, smoking in front of little boys and girls is hazardous to their health if they have healthy little lungs, let alone bad lungs already.

I'm not a fan of making a laws just because, but I'd be willing to make an exception for a law to make it illegal to smoke in front of kids. Then I could take half the mom's who bring kids to the hospital and put them away for 30-90 days for causing their kids to get sick. Maybe that's what's needed to knock some sense into them.

Tonight I took care of yet another little boy who was having an asthma attack. And I didn't even need to ask my usual 101 questions to know the mom smoked in front of her child, as they both smelled of smoke. Yet I asked anyway, and the answer was a nonchalant, "Yes."

Pathetic, I say. Just pathetic. Pure stupid.

Is there any way possible that any parent in existence in the United States today can possibly not know how stupid it is to smoke in front of their kids, let alone a kid with asthma.

You sit there and watch your kid have an asthma attack. You love your child so much that you take him to the ER when he is having an attack, yet you don't know enough to not smoke in front of him. How stupid. How stupid you are.

Let this peon of an RT tell you something: If you want to ruin your own lungs and your own life by smoking, you have that choice. Your son doesn't have the same choices you have. He has to live in the atmosphere you create.

It's your job to protect him. Do not destroy his life too. Don't smoke in front of him.

That is the thought of the day. Thoughts anyone.

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.

Cardiac asthma should not be treated as asthma

I have spent so much time writing about and educating nurses and students about cardiac asthma that I have decided it needs a post of its own.

And, considering about half of all breathing treatments I do are either for pneumonia or cardiac asthma, I am hereby convinced that even doctors have no clue what the difference between true asthma and cardiac asthma is.

So, that is what we will learn in today's class:

According to the Mayoclinic.com, here is the definition of Cardiac Asthma:

The term "cardiac asthma" refers to wheezing associated with congestive heart failure. It isn't true asthma.

As a result of congestive heart failure, fluid can build up in the lungs (pulmonary dema). This causes signs and symptoms — such as shortness of breath, coughing and wheezing — that may mimic asthma. True asthma is a chronic condition caused by inflammation of the airways, which can lead to breathing difficulties.

The distinction is important because treatments for asthma and heart failure are very different

Cardiac asthma is mainly caused due to increased pressure in the pulmonary vessels causing fluid to fill the air sacs, "preventing them from absorbing oxygen," and making the person feel extremely short-of-breath.

This same increased pulmonary vessel pressure in turn squeezes the bronchioles and causes the wheeze and other symptoms that mimic real asthma, and this is why this "problem" is quite often mistaken for asthma and treated with bronchodilators.

I was flabbergasted when I found this article a few years ago, because I knew I was correct in this, but have not found any evidence to support my claim other than what I learned one day in respiratory therapy school. However, even in RT school, one of my teachers mentioned cardiac asthma and cardiac wheeze, but did not give any further detail.

So, here we have it -- the further detail; the evidence that cardiac asthma and asthma have similar symptoms but must be treated as unique illnesses.

When Cardiac Asthma is treated as bronchospasm, all we are doing is putting in more fluid already fluid filled lungs. What we need to do is give a diuretic to get rid of the fluid and, if the heart is causing the pulmonary edema, perhaps provide drugs to increase the contractility of the heart to reduce the pulmonary pressure.

Other than the heart, there are other diseases that can cause pulmonary edema and, thus, cardiac asthma, and these include pneumonia, exposure to toxin, and high altitudes. It is the job of the nurse, the respiratory therapist and (ahem) the doctor to determine the cause of the symptoms and treat the symptoms appropriately.

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 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? Is that not the job of the doctor? Or is it the pharmacist?

The pharmacy here gives patients a printout about new medicines, but that's only something knew they've been doing. Only once in my life did a pharmacist ever pull me over and say, "Hey, do you think maybe you are using that thing too often?"

I might have told that pharmacist something like, "Yep, I'll try to behave myself in the future." And then went home and continued to abuse whatever medicine I was abusing -- probably Albuterol at the time.

My doctor never one time told me that I was using this medicine too much. Never. In fact, the only time my doctor ever said anything to me about this was when I brought it up. Then I got the feeling he was telling me what I wanted to hear, and then he promptly left the room before I could ask another stupid and annoying question.

While it is possible that Singulair might have a small chance of causing depression, there is also a good possibility this occurrence of depression was a mere coincidence.

I see this a lot right here in the hospital with Ventolin. I give a breathing treatment with Ventolin to a person, he coincidentally vomits, and the next day I come into work and the patient is ordered on Alupent because the doctor decided the patient was allergic to Ventolin.

Now we have this new drug on the market called Xoponex, which is marketed by the company as not causing the same side effects as Albuterol, and yet, when I give Xoponex, those patients get just as jittery as they were when they used to take Albuterol. Recent studies show there is no difference between the two drugs when it comes to side effects, yet each doctor still holds his or her own opinion.

Many times I meet an extremely short-of-breath patient in the emergency room and note the heart rate is 130. Then I give two breathing treatments to this patient, the doctor goes into the room, notes the heart rate, and says to the patient, "I'm not worried about your heart rate. I think it's just because of all the stimulation from the breathing treatments."

Then the doctor orders another treatment, this time with Xoponex. I don't have a chance to tell the doctor that he is foolish, that the heart rate was up before the patient even had one dose of Albuterol. And, chances are, that his heart rate was up because he was in distress and hypoxic, not because of any medicine he was given.

Now I'm not saying these medicines don't have side effects, nor am I concluding here that Singulair does not cause some people to have suicidal thoughts (however I have yet to have them), or that Albuterol never increases your heart rate (I don't see it very often though), but I think that many of these medicines get a bad rap.

I think these medicines get a bad rap, despite all the good they do, because people who are doing the judging of them refuse to use a little good old fashioned common sense. Instead of assessing the entire situation, they just blame the medicine.

If you take a medicine and you truly notice that something new or different is occurring, then you should stop taking it and consult your doctor. Let's just make sure it's truly a side effect, and not simply an aberration.

Yes, some medicines that are supposed to have euphoric results turn out to be bad after all, like that one medicine that was supposed to be the ideal weight loss medicine that ended up causing cardiac problems. But some medicines that are good, are simply misjudged.

And I certainly pray they don't take a good drug off the market based on a misconception, or symptoms or death that results from lack of patient education more so than the medicine itself; especially when these medicines have the potential to help so many people.

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

Monday's class: My response to your queries

This post is my weekly attempt to answer Internet search engine queries that lead someone to clicking onto my medblog.

I know that most people click on my site and leave two minutes later frustrated that my site is not what they were looking for. When, in actuality, if they would have hung around a bit, had a cup of coffee with me, they may have found the answer they were looking for.

Here we go:

1. giving mucomyst iv : I had never heard of it. However, upon doing a quick Google search, I found that it can be given IV. Here's what RXmed.com had to say: "Administered orally or i.v., as an antidote to prevent or lessen hepatic injury which may occur following the ingestion of a potentially hepatotoxic quantity of acetaminophen."
   
2. asthma attack albuterol nebulizer : The medicine has the ability to generate instant relief when a person is having trouble breathing. This and COPD are the two main indications for this medicine.


3. how are asthmatic attack in adults graded : Adults can use a peek flow meter just like children, and they and their doctor can adjust their therapy according to how well they do on their peek flow, likewise pulmonary function testing can be used for this too. Likewise, all asthmatics should maintain an asthma diary to keep track of your symptoms so the next time you see your doctor she knows if current medicines are working, and so she can change the plan accordingly. For more information, click here.
   
4. copd and ventolin treatment : Check out my answer for #2.


5. vaponephrine : This medicine is the watered down version of Epinephrine that can be used as as a bronchodilator like Albuterol, but it has a greater effect on the heart, and if this medicine is given, it is recommended the doctor keep the patient for 1-2 hours after therapy to watch for rebound. Vaponepherine (Racemic Epinepherine), is mostly used for croup, which causes swelling of the upper airway above the vocal chords. At our hospital, it is used only as a last resort, and whether or not it really has the desired effect here is still open to debate. Personally, I don't think it does anything. Vaponepherine is also used on occasion in adults with swollen upper airways, which is usually due to post intubation. Again, it is used here as a last resort. Some doctors do not like using it, and some do. There is one other illness that studies show this medicine to have some efficacy, and that is for young children with RSV. New RSV guidelines recommend trying this medicine to see if it has a benefit, and if not, to discontinue it. Studies have also shown that severe asthma patients do respond to Vaponepherine, especially among patients who have been puffing on their inhaler all day and have saturated their beta receptor cells with Albuterol.


6. obtunded with ards : I do not deal with ARDS patients much at my hospital, so I will have to defer answering this question. The most important thing I would recommend regarding obtunded patients is that they not be given tidal volumes according to their actual weight, but ml/kg ideal body weight. At Shoreline we use 6-10 ml/kg ideal body weight.


7. acute renal failure; respiratory therapist : We do deal with these patients on occasion, and the most pressing respiratory issue here would be pulmonary edema and the patients inability to excrete urine. How these patients are treated is up to the physician, and is usually based on the patient's signs and symptoms. If the patient is in respiratory failure, RT may be required to draw an ABG or, if need be, intubate the patient and set him or her up on a ventilator. At shoreline, if the patient needs dialysis, we ship.


8. pneumothorax : I had a COPD patient with severe respiratory distress once who was initially ordered to receive continuous Albuterol treatments. I started the treatment, listened to the patient, and thought I heard a rub on the right side. Since that can be a sign of a pneumo, I reported my findings to the doctor, who put in a chest tube. Soon thereafter the patient was transferred to the floor and was breathing easy.


9. respiratory therapy teaching materials for kids : You mean for asthma? There is plenty of it. When I was a kid I got a big box of fun stuff to play with that taught me about asthma. I even had this cool game that nobody wanted to play with me. I think I even still have it somewhere in my basement in a box. Perhaps I should try selling it on EBAY. For a good website, click here.


10. respiratory floor charting form : We actually had a good one when I started working at Shoreline, but we've been doing computer charting the past eight years or so. I don't know about other hospitals, but our computer charting is very cool.


11. 90 cartoons large dragon in a cave : Technically speaking, there are no dragons here.


12. are blow-by treatments effective for pediatric patients : Yes. You do lose a lot of medicine to the atmosphere, but I think they are still very effective. That's my personal opinion. I know there is a lot of research that says otherwise, but my personal opinion says yes. We use blowby treatments with almost all of our young kids.


13. protocols of hypokalemia : There is nothing in the RT bag of tricks for this.


14. protocol for bi pap : We do not have a written protocol, however doctors usually write the order for Bipap, and we determine the settings on our own. I wish we were provided this same responsibility with vents.


15. how much does an hour of respiratory therapy cost? : The hospital charges for the procedures we do, not for our time. I wish that I was paid for each procedure I did. If that were the case, I would never complain about a useless breathing treatment, and we RTs would be rich.


16. as a respiratory therapist should i cross over in nursing : If you think you can handle it, I would highly recommend it. The pay is better and there are far more opportunities.


17. does albuterol have alcohol in it : I wish.


18. how many days should it take to know if singulair is working : It usually takes 7-10 days to get into your system. This is one medicine you need to keep in your system, unlike other allergy medicine.
    
19. how long does advair stay in your system : Advair should never leave your system. It is one of the preventative medicines you take on a regular basis and never stop unless your doctor says otherwise.
    
20. give ventolin before atrovent : A good question. Ventolin opens up the bronchioles immediately, so it only makes sense to give Ventolin first. However, one of my teachers argued that Atrovent opens the large airways, in which case, if he is right, then Atrovent should be given first. You decide. What do my fellow RTs think about this?
    
21. vents bipap nursing : I think it's important for RNs to understand some of the basics of both these machines. I don't think RT needs to be called every time a BiPAP patient wants to take off his mask, so the RN should know how to do this. The same with the vent. Especially being the lone RT at night, I teach my RN friends how to do certain things on the vent, like preoxygenate, turn it on standby during suctioning, etc.

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact us at Freadom1776@yahoo.com, or RTcave@yahoo.com.

That concludes today's class.

Singulair: Another asthma miracle drug

This is my weekly focus on patient education, where I will discuss everything you need to know about (fill in blank).

The theory here is that, as a patient, I think it's good to go to your doctor armed with as much knowledge as possible. I call these posts patient wisdom, and you can refer to them at your convenience by clicking on the patient wisdom link near the top of this blog.

Today's focus is on allergies, asthma and Singulair.

I talked to one of the doctors I respect very much a few months back while I was working, and somehow the topic of discussion changed to me, and how much I love spring, but hate how miserable my allergies are at that time of year.

He said, "I think that every asthmatic should be on Singulair. I prescribe it for all my asthma patients."

So, when I went to my doctor, I said, "So, what would you recommend for allergies?"

My doctor said, "Well, did you try over the counter stuff, like Drixorol, Claratin, benadryl and that type of stuff?"

"Yeah, I've tried it all over the past 25 years, I even had allergy shots as a kid. None of it seemed to work. I was just wondering if you knew of anything stronger I might try, not that I really want more medicine to take or anything."

"Well, there is Singulair."

"Ah, that's what I was leading at. I didn't want to say Singulair just in case you had a better idea."

"Yeah, I suppose we could try that."

There, I got what I wanted. "Since spring is right around the corner, I will know right away if it works."

So, how do you know if Singulair is right for you?

Pretty much, based on my research, Singulair has proven effective for anyone with Allergic Rhinitis (hay fever) and asthma/allergies. For the most part, these two tend to go hand in hand.

Thus, if doctors could somehow prevent allergies, they could control asthma.

Finally, in 1998, after spending millions of dollars and 63 years studying leukotrines and working on a way to block their release, Singulair was approved for use by the FDA.

Singulair has an active ingredient in it called Montelukast sodium, which blocks the action of leukotrien, thus preventing allergies, and preventing bronchospasm caused by allergies, and, in turn, preventing asthma.

So lets back up a bit. What the heck are Leukotrienes? Better yet, what causes allergies in the first place?

When our bodies sense a foreign substance that might cause harm has entered the body, such as a bacteria or virus, it releases chemicals to attack the foreign substance. This is the bodies normal immunologic response to prevent and fight diseases. This is a good response by our immune system.

However, in some people, those of us who are prone to allergies, our immune system responds to harmful things, but also things that are relatively harmless, and generally cause no reaction in people who do not have allergies. In essence, with allergies, our body is fighting itself, and this is bad.

These harmless things that cause allergies are called allergens. Some common allergens are pollens released from trees, mold, hay, grass, dander, and food.

For the most part, if something causes us to have an allergic response, or asthma, we try to identify our triggers, in this case allergens, and avoid them. If you only have one allergen it might be easy to avoid, but for us asthmatics who are allergic to a ton of things, the only way to avoid all of them is to live in a bubble.

Now we all know that's not possible, or at least extremely difficult.

To give you an idea of the allergy process, I'll provide here a pithy example.

Say you are prone to allergies and breathe in a molecule of pollen. Your body fails to recognize it as harmless, and releases a chemical called pollen IgE antibody that binds to mast cells.

Now, at this point, nothing really happens, but the next time you are exposed to pollen, the IgE primed mast cell releases chemical mediators which attach to specific cells in the body causing inflammation.

Leukotreins are one type of chemical mediator which is responsible for inflammation, and are the culprits responsible for causing bronchoconstriction (tightening of the muscles around the airways) and swelling of the airways.

Thus, if we could find a way to block the release of these leukotriens, we could stop, or greatly diminish, an allergy attack, and thus an asthma attack.

And that's where Singulair comes into play. It blocks the release of leukotreins.

It has been proven effective for the management of allergies in asthma, and allergic rhinitis. It usually takes 3-7 days to start working, so, unlike antihistamines, it does not have an immediate effect, and must be taken on a regular basis (every day) to be effective.

In other words, even if you have no symptoms, you should never stop taking this medicine, unless otherwise prescribed by your doctor.

Singulair has not been proven effective as treatment of itchy eyes, itchy nose, sneezing and runny nose. If these symptoms continue to be problems for you, you might want to try an antihistamine, which can be purchased over the counter.

There is one other use for Singulair, and that is for people who have excercise induced asthma.

According to Health Library at CNN.com, "Because exercise-induced asthma has the same symptoms and results from the same airway reaction involved in regular asthma, standard asthma medications can control it."

Patients who experience excercise induced asthma but don't necessarily have a problem with allergins, and do not already take the medicine on a daily basis can take the medicine two hours prior to excersising, but not again for 24 hours thereafter.

Some patients have managed to control their asthma, excersise induced asthma and/or allergic rhinitis with the use of Singulair alone. However, some asthmatics may need other prophylactic therapies, such as Chromolyn or Advair and an occasional use of a rescue medicine such as an Albuterol inhaler.

So there, in a nutshell, is everything you need to know about asthma related allergies and singulair.

For more information, check out this link. Also check out this, the official website of singulair

That concludes today's class.

Monday's class: My response to your queries

This post is my weekly attempt to answer Internet search engine queries that lead someone to clicking onto my medblog.

Of the 500 queries in my stat counter's memory, I have picked some of the most interesting queries. Keep in mind I do not answer queries if the page the person landed on would have provided them with an appropriate answer.

Yes, this is supposed to be my Monday feature. For now on it will be. We'll also have class on Tuesday and Wednesday as well starting next week.

Here we go:

1. copd patient with left side chest pain: The emergency room staff would treat this as cardiac related until test results show otherwise.
2. What year was Albuterol invented?: I had to look this up. According to Wikipedia, "Salbutamol became available in the United Kingdom in 1969 and in the United States in 1980 under the trade name Ventolin." I never knew about it until 1993.
3. what's it like to be a respiratory therapist? It's rewarding knowing that your skills saved a life or improved someones breathing. We also get to share our vast respiratory knowledge by educating our patients about their respective disease process, and how to live with their illness. We spend a lot of our time going room to room doing breathing treatments that help patients breathe better. I've met a lot of neat people and have had many great conversations doing this. Another part of the job is taking care of critical patients, maintaining their airway when needed and, if necessary, setting them up on life support. This, in my opinion, is the most rewarding and challenging part of the job.
4. Duoneb croup: First of all, croup is caused by a virus, and typically only effects children. It causes swelling of the smooth muscles of the upper airway above the vocal chords, and, as the child is breathing in, you will hear a harsh sound we refer to as stridor. The child's cough may sound like a bark. Duoneb will not benefit croup. However, if there is an underlying bronchospasm component (asthma) along with the croup, Duoneb will relax the lung muscles and make it easier for the patient to breathe. Usually for croup we use a cool mist aerosol to try to relax the muscles of the throat, or, if necessary, we give a racemic epinepherine treatment. Sometimes this works, sometimes it doesn't. For the most part, whether this is used depends on the doctor's preference. The Racemic Epinepherine will relax the smooth muscles in the lungs, but theoretically it will also relax the smooth muscles in the throat, which is what is causing the croup, and is why this is usually the aerosol of choice for croup.
5. Albuterol potassium: Albuterol can lower potassium if it is given excessively. If you use it as prescribed it should not lower your potassium. This, however, is something that should be watched when a patient is receiving continuous breathing treatments in the hospital setting, and might be a good reason not to overuse your Ventolin inhaler at home.
6. nursing home respiratory therapist: Currently, Medicaid won't pay for an RT in the nursing home in Michigan, but I'm not sure about other states. However, before the law was changed, I did work in a nursing home for a while. It was a very slow paced job where pretty much all I did was breathing treatments and incentive spirometers -- lots of incentive spirometers. Occasionally I'd be called to assess a patient in distress, in which case I'd usually recommend sending the patient to the hospital.
7. still use mist tents: Not at my hospital. We hid them in the basement where they are currently collecting dust. We find that it is better for the patient, the parents and the hospital staff to simply use a pediatric nasal cannula if the patient needs oxygen. If a patient needs the mist, then we simply set up a cool mist aerosol. However, I've only done the later in the emergency room.
8. nebulizer for cough spasm: Sure. You can try it. If there is an underlying bronchospasm component, a nebulizer with Albuterol might help.
9. copd sucks: I imagine it does. However, there are many things you can do to help you cope with this illness. Click here for a good article on coping with COPD. Or click here to check out what the COPD doctors and scientists at National Jewish Medical and Research Center have to say about coping with COPD. And here is a good blog of a COPDer who has written many great posts on how to cope with breathing illnesses.
10. asthma attack every 2 weeks: If you are having an asthma attack every two weeks, then you should definitely be on some preventative medications, and you should learn what triggers your asthma and how to avoid them. There is no cure for asthma, but there is no reason why any person in today's world should'nt live a normal productive life. For more information you can check out this link. Another good link for asthma information I will link to right here. You should fully educate yourself about asthma and talk to your doctor about how best to manage it.
11. oxygen weaning protocol: I've never worked at a hospital that doesn't have one. We are allowed to wean oxygen to maintain an SpO2 of 92% or greater on any patient ordered on our oxygen protocol or ventilator protocol, which would include most of our patients. If the oxygen does not stay above 92%, we may increase oxygen to whatever the original order was. However, if a patient suddenly needs a lot more oxygen, say from room air to a 50% venti mask, common sense dictates that a doctor should be notified.
12. Respiratory therapy stories: This would be a good idea for a post. What is the most exciting thing that ever happened to you as an RT? Or what was the weirdest thing you ever saw? I had a an end stage COPD patient once who was extremely short of breath and she shouted, "I JUST WANT TO BE WITH THE LORD!" She did right then.

Keep in mind I receive hundreds of queries a week, and I am limited in space on this weekly column.

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact us at Freadom1776@yahoo.com, or RTcave@yahoo.com.

That concludes today's class.