The carbon copy blue bloater

Disclaimer: The following was written by an anonymous author. Any resemblance to any person living or dead is merely coincidental.

You'd think with only five patients on my clipboard I'd have an easy night, right? Wrong! I have five very highly demanding patients. And, the funny thing is, they are all exactly the same. In fact, they all seem to be carbon copies of the other.

Yeah! Tonight I have the carbon copy patients. They all have or are:

1. end stage COPD and lung cancer
2. blue bloaters
3. severe dyspnea with even minimal exertion
4. members of the 50/50 club (chronic po2 50 and co2 50)
5. basically bed bound or recliner bound
6. severe anxiety
7. severe restlessness
8. highly demanding
9. somewhat annoying after a while
10. challenging
11. enjoying to talk with
12. exceptionally cordial and pleasant underlying dispositions
13. insist you stay in the room until their treatment is done
14. want you to stay in room after the treatment is done ("Please, don't go!")
15. clock watchers
16. want their treatments every two hours
17. require BiPAP to catch their breath
18. refuse to wear their BiPAP most of the time
19. call to have BiPAP hooked up when they get panicked
20. demand you increase their nasal cannula liter flow at their request (one insists on the liter flow being 10 lpm even though he's wearing a nasal cannula)

Thank you for the opportunity to share my piece.

COPD blogs and resources

I preach over and over again that if you have a lung disease you must keep up to date on that disease. You must, in a sense, become an expert. This is especially true if you have COPD.

There are some sources for COPD wisdom on the Internet I utilize on a regular basis. Yet, as a search the web I find tons more. Below I'm going to list the COPD resources on the web that I use plus some others people have referred me to.

If you want me to add your site to this list, or if you have a sit you use that you think would benefit others like you, please email me or leave a comment on this post and I will add it to this list.

1. Roxlyn's COPD blog
2. COPDConnection.com
3. COPD News of the Day
4. COPD and so much more
5. Living out loud with COPD
6. About.com COPD blog
7. Love your lungs, breath for life
8. COPD Alert (community support and advocacy group)
9. Lung care cure community
10. Breathing: Your guide to living well
11. COPD Support1.com
12. Guide to quitting smoking (American Cancer Society)
13. COPD Support
14. National Heart Blood Institute (What is COPD?)
15. American Lung Association
16. National Jewish Health (COPD)
17. CPAP, Sleep apnea, snoring

Books

1. COPD for dummies
2. 100 questions and answers about COPD
3. Some more books here
4. Coping with COPD: Understanding, Treating, and Living with Chronic Obstructive Pulmonary Disease
5. The Chronic Bronchitis and Emphysema Handbook
6. Asthma and COPD, Second Edition: Basic Mechanisms and Clinical Management (For medical people or for those who want more indepth information)

Your RT Queries: How do you treat thrush?

Every week I check my statcounter to see who's typing things into Google or Yahoo and being linked to my RT Cave blog. Assuming the queries were not answered, I provide in this spot each week my humble responses.And, hey, if the query is comical, it deserves a comical response. If it's serious, I treat it as serious. That in mind, here are this weeks queries:

1. can atrovent be given q2: Absolutely. This is a very safe medicine that can be used Q2 hours and even continuous if needed in the emergency room. However, I wouldn't recommend using it any more frequently than Q4 at home. You really should have no reason to use it more often than that. If you do, you ought to be calling your doctor.

2. can a albuterol inhaler cause high co2 in your blood?: No. Albuterol in no way is related to CO2. Albuterol is a bronchodilator that relaxes the air passages in your lungs and can make it easier to breath.

3. would symbicort stop croupy cough?: Symbicort is a medicine that is meant to be taken no more often than twice a day and is not recommended to be used for acute asthma symptoms. Symbicort will not relax the muscles in the throat and should have no effect on croup or a croupy cough. However, some asthmatics get a croupy cough as one of their signs of asthma, and if this is the case a rescue medicine like Albuterol might help. Again, symbicort should never be taken more often than twice a day (BID).

4. advair substitute: Symbicort is the best substitute for Advair. There are also some generic Symbicort inhalers available.

5. ippb therapy: My co-writer for this blog is going to write a post for the RT Cave stating that IPPB is good in some rare cases. So, stay tuned!!!

6. ventimask 50% bad: It depends. If 50% FiO2 is required to maintain an SpO2 of at least 90% then this can be a good thing.

7. atrovent in tx of croup: I can find no documented evidence that Atrovent does anything for croup. However, if you can find any such evidence let me know and I will publish it on this blog.

8. can i smoke while on ventolin: Yes you can. Smoking is good for your lungs and is highly recommended, especially if you have asthma. Just Kidding! Of course you should stop smoking if you need to use Ventolin. Smoking is a trigger of both COPD and asthma and any doctor wouldl highly recommend you quit.

9. white stuff growing on roof of mouth inhaler: Sounds like thrush. This is a common side effect if you are using a steroid inhaler. This can be prevented by rinsing your mouth after each use. It can be treated by calling your doctor and getting either a pill or a rinse. I prefer the pill because you only have to take it for four or five days. For more information click here. I mention the medications that will help here.

10. respiratory therapist who became a physician: I think I've written about this before, that I think RTs would make the best doctors. I highly recommend every doctor step on the RT rung of the ladder on the way to the more prominent career of physician.

If you have further questions for me please contact me.

Weekly asthma FAQ

Every day at MyAsthmaCentral.com we get lots of asthma related questions. Below are some questions I thought my readers at the RT Cave would enjoy.

Question: I have been getting recurring pneumonia, could this be from advair?

My humble answer: You are not the lone person to come up with this idea as there has been much written on it, as is the case with this post here and this link here, and this one, and again here in this study. However, this study shows budosenide (an oral corticosteroid siilar to that of which is in Advair) does not cause pneumonia. So, I would imagine more research will be needed to come to a conclusion either way. The ideal thing for you to do is continue talking with your physician to make sure that the benefits to using this medicine outweigh the risks. In most studies, Advair (and Symbicort too) have been proven to be very effective for managing inflammation for asthma and COPD patients.

That aside, there are certain things you can do to try to prevent getting pneuonia that I describe in this post here: "Pneumonia: here's what you can do to prevent it."

Question: What in the body happens to cause asthma?

My humble answer: You've come to the right place to find everything you need to know about asthma. The best place to start is by clicking here or, better yet, here. By following these links you should get a good overall understanding of what asthma is and what "triggers" an asthma attack and what an asthma attack is.

No one really understands what causes a person to develop asthma in the first place, but there are theories, such as this one I wrote about.

The airways of most asthmatics are always inflamed (swollen) to some degree. Depending on the severity of this inflammation determines how bad one's asthma is and how sensitive the air passages are to asthma triggers.

When an asthmatic is exposed to his or her asthma triggers, this triggers the asthma response you can read about in the second link above. This ultimately leads to the air passages in your lungs (check out this link) to become increasingly inflamed (swollen) causing them to constrict (become narrow). When this happens air you breath can enter your lungs, but the narrowed airway traps the air in your lungs (this is called air trapping). Since an asthmatic during an asthma attack has this extra air in his lungs, it feels as though he can't get air in, but the truth is he can't get air out. He then feels like a fish out of water.

Fortunately there are medicines to treat an acute (ongoing) asthma attack like this and even more medicine to prevent an asthma attack. You can read about asthma medicines here.

If you want to read a very thorough writing about what asthma is, you should check out the asthma guidelines I will link to here. Actually, the answer to your question should be in this section.

Good luck.

Question: I have asthma and taking 4 life transfer factor as remedy. i was told by a friend that he has taken 4life transfer factor pills for his immune system and that his asthma has gone away . is this 4 life product as good as they say it is ?

My humble answer: I can neither deny nor confirm this claim. However, I'm sure if this worked to "cure" asthma it would be all over the news and on the front pages of this site. You have to realize that asthma has a tendency to appear to "hibernate" for weeks, months, and sometimes even years. It may be a coincidence that your friend started taking this 4 life transfer factor at the same time his asthma went into hiding. However we want to remain open minded, so the best thing for you to do if considering this is to discuss it with your asthma doctor and continue to keep up on your asthma research for the latest asthma wisdom.

Question: Coughing lots especially at night. Sometimes it leads to vomiting. My doctor says I just have a cold. Is he right?

My humble answer: We really cannot diagnose over the Internet. It is not completely abnormal for a coughing spasm to lead to vomiting and a headache. A common cold can cause nasal drainage which would induce a cough. Bronchitis, asthma, and a lung infection may also cause increased sputum production and induce a cough. Which one of the above is causing your symptoms is something only your doctor can determine.

Question: I am 25 yrs old girl I always get breathing problem whenever i cry a lot or get tired. Is this a symptom of Asthma?

My humble answer: Actually, what you are describing is not a symptom of asthma. To see what the symptoms of asthma are click here. That said, emotions can be an asthma trigger. Asthma triggers are things that can "trigger" an asthma attack. To learn more about asthma triggers click here.

There are some things you can do to help prevent emotions from effecting your asthma. First, you should discuss this with your asthma doctor. Second, you might want to learn and work on some relaxation exercises. When you get emotional you can work on "relaxing" and this can help prevent this from causing asthma.

Better yet, setting aside 5-15 minutes each day to concentrate just on relaxing your body might prevent emotional asthma altogether. Trust me, I've tried this and it works great.

When I was a teenager I had asthma that was triggered similar to what you describe here. Whenever I was tired, stress or anxious I'd have trouble breathing. Fortunately I knew a great asthma nurse who taught me some great relaxation techniques. One I mention in this post, although this post describes relaxation techniques better.

You should also mention this to your doctor, because he or she might have some more ideas that might help.

If you have any further questions email me, or Visit MyAsthmaCentral.com's Q&A section.

The link between asthma and COPD

A doctor told me once that if you have childhood asthma that doesn't go away when you grow up you are said to have COPD. As a former child asthmatic. He also said once, "If you ever smoke I might as well just kill you."

I think about what he said often. Recently I decided to do some research.

I've learned that most of the time when we refer to COPD (Chronic Obstructive Pulmonary Disease) (COPD) we are referring to people who smoke. This is rightly so because, according to nationaljewishhealth.org, 94% of those with COPD are people who smoked cigarettes.

That said, there are still 5% of COPD patients that often go unaccounted for. Almost 1% of these get COPD "by genetic-based deficiencies in an enzyme called alpha-1 antitrypsin," according to National Jewish.

The other 5% get COPD either get the disease from "exposure to various types of dust such as coal, grain, or wood or by recurrent or significant lung infections in infancy and early childhood."

People with asthma are among those most likely to be hospitalized with lung infections, and therefore asthmatics fall into this 5% too.

So now we see where the slight overlap of Asthma and COPD comes into play (see picture). A small percent of asthmatics, if their asthma is not controlled appropriately, can develop lung scarring over time that results in permanent lung damage that can cause them to have chronic persistent asthma/ COPD.

It is these asthmatics who are your hardluck asthmatics (I think). It is these asthmatics who are staged to become your bronchodilatoraholics, and who require the use of rescue medicine on a daily basis.

I have written here before how I have a need for my rescue medicine on a daily basis for relatively mild symptoms, and have to constantly be vigilant for my asthma triggers because my lungs are "more sensitive" than the lungs of most asthmatics.

I also learned that asthma is often misdiagnosed as bronchitis. From my medical records I've learned I had frequent bouts of "bronchitis" before I was 2. Chances are I was misdiagnosed, because I was diagnosed with asthma when I was 2-years old. Plus there were lots of asthma attacks. All of this, I bet, caused my asthma to get as bad as it did.

Keep in mind here I'm just speculating, but it makes sense to me. To be honest, I don't think even the worlds formost asthma experts would know exactly why asthma sometimes gets so bad. Although there are many theories.

There is a small area where the circles of asthma and COPD overlap (again, see picture). I would guess that less than 10% of asthmatics fall into the COPD category. Yet I've read in "Egans Fundamentals of Respiratory Care," that anywhere from 15-70% of those with COPD have the asthma gene.

From my own asthma history and from my recent research I've learned two things I would like to share with my asthmatic readers.

1. Childhood asthma is better diagnosed and better treated today as compared to when we were kids. So chances are our asthmatic kids won't get as bad as we are, and won't push their asthma into the COPD category.

2. If you had asthma as a kid you better never touch a cigarette. If you do you're playing with fire (literally), as you are risking pushing your asthma into the COPD category, as I would imagine the Recovered Asthmatic is doing.

Swimming and asthma

I've found something that bothers my asthma every time -- swimming. I can still do it, but I most certainly need to pace myself.

It has been written by many asthma experts that swimming is among the best exercises for asthmatics. When I was a kid I used to go swimming all the time. We had a neighborhood pool and a beach a mile from where we lived. Yes I had trouble breathing when I exerted myself under water sometimes, but for the most part I handled it pretty well

When I was at the asthma hospital in 1985 the asthma experts there had us asthmatics swimming at least three times a week. So even way back then (I make myself sound old here) the experts were recommending swimming for asthmatics.

I don't swim nearly as much as I used to, although I do take my kids for a swim in Lake Michigan from time to time since I live so close to it. And when we go on vacation I take my kids for a dip in the pool. Yet one thing that remains consistent: swimming makes me short of breath.

I stay physically active and I even run without having trouble with my breathing. I wasn't always able to run as I also have exercise induced asthma, although my asthma has not bothered me when I exercise lately. So this makes me wonder why it would be EIA causing my shortness of breath while swimming. Although this is a good possibility.

As my regular readers know by now I had hardluck asthma until a few years ago. I don't have trouble breathing throughout most of the day anymore. When I do it's usually mild and is resolved with a puff or two of that blue inhaler we call Albuterol.

Yet, despite what I write here, every time I get in the water my chest gets tight.

I guess I noticed it more on this vacation because I was in the water every day. And since my kids are older and now know how to swim I was actually able to do a little swimming on my own. And after that first time racing my son to the other end, I noticed my chest was heavy. I had to get out and rest. I didn't get all the way out, just sat on the top step with my chest out of the water. I doubt anyone watching had a clue why I was sitting there. I don't think I was obviously short of breath. I tried not to be obvious anyway.

While I usually can make it from one side of the pool to the other without coming up for air, I was only able to do this once and I was done. I had to sit and rest. I had to literally get my chest out of the water to get relief. And that's what made me wonder: was it the exertion under water that hit me (EIA), or was it the pressure of the water against my asthmatic lungs. Or was it the chlorine. However, if it was the chlorine then I wouldn't get short of breath while swimming in the Lake, and I do.

The next day I went under water and was fine until I challenged my son to another race. I was able to beat him a second time, but that was while dealing with a tight chest and taking in only what felt like 3/4 of a breath each inhalation. I wasn't completely miserable by no means, but there was definitely some discomfort.

The next day I decided I was just going to put my chest under water and not exert myself. I wanted to see if just the water pressure alone would make me short of breath. Well, I'm not the kind of person to just sit still, and after a few minutes I was tossing my 11-year-old into the deep end so he could have his fun. Then my 6-year-old wanted to get into the action. Before long my chest was tight. Yet I continued to toss my kids for some time. Eventually, though, I knew it was time to quit.

Now I have to add that the shortness of breath I got by being in the water was not relieved by my bronchodilator. In fact, after the first few times I decided not even to bother using it. It was the kind of shortness of breath that you had to wait out. If you have asthma maybe you know what I mean. I wasn't sick enough to panic because I had been here before. I JUST KNEW I would be fine if I just waited it out.

But I didn't want to wait it out. I wanted to swim some more with my kids. So I did. My son mentioned something about this to me about the fifth or sixth time we went into a pool. He said, "Dad, why is it that every time we get into the water you race me less and less?"

Well, I didn't want to bother him with my problems. I wanted him to be having fun. And I had a great time too. I knew that once I got out of the water with the kids and rested a while I would be fine. I knew my asthma was controlled enough (I'm a gallant asthmatic) that I'd be perfectly fine within 10-15 minutes post water.

This turned out to be true every time. I'm telling you, it's an awesome feeling and a comforting feeling when you know your asthma so well you know exactly what you can and cannot do based on the type of shortness of breath you experience.

(Believe it or not there are different types of shortness of breath; different feelings you get in the chest. This is a topic I think I will take up in another post).

And the type of shortness of breath I was feeling was one I knew I would be fine once I rested. It's power I suppose. It's power over myself. It's vigilance. If you have asthma as long as I have you know what I mean. After a while you just know yourself; you know your asthma; you know exactly what works and what doesn't; you know exactly what to do and when to do it.

It's also an awesome feeling as you slowly but surely notice the pressure in your chest giving way, and the air getting deeper and deeper into your lungs with each breath. And all of this without taking one puff of your rescue inhaler. In a way, it creates (I wrote about this before) a feeling of euphoria. Likewise, it creates an appreciation for breathing. You experience this once and you'll never take breathing for granted again.

Swimming is fun and I'm going to do it again next chance I get. And you can bet I'll be holding my breath the length of the pool, or doing laps. You an bet that some day soon I'll be wrestling with my son under water, or tossing my kids into the air and watching them giggle while they splash in the water. It's fun. And no asthma beast is going to take away this fun from me.
Another thing I wonder is if I swam every day if my lungs would get even stronger and these episodes of shortness of breath due to water immersion would cease.

See I'm curious this way.

Here's why we don't have protocols

Ideally, according to Egan, a protocol would work like this:

1. Therapy can be adjusted more frequently in response to changes in patient status.


2. Physicians can still be contacted for major changes, but not minor adjustments, thus reducing nuisance calls.


3. Consistency of therapy can be maintained and nonpulmonary physicians can use appropriate up-to-date methods by simply requesting that protocol therapy be used.


4. RCPs become actively involved in achieving good patient outcomes instead of performing rigid tasks. This enhanced responsibility attracts and retains better educated qualified practitioners.

Doctors here at Shoreline don't want any of these, and therefore have elected to ignore pleas of lowly RTs.

1. They don't want frequency to be adjusted. Thus Q4ever for everyone.
2. They aren't worried about nuisance calls because when they get them they double the frequency and add IPPB that RTs hate.
3. Nonpulmonary physicians don't have to worry because Q4ever works for everyone regardless of diagnosis.
4. Physicians don't believe RTs have are smart enough to know who needs therapy. Likewise, RT Bosses don't have to worry about attracting and retaining qualified RTs because there are no other RT departments in this area for us RTs to go.
5. Our Doctors loved the year 1980, so why use 2010 wisdom.