Peak Flow Meter Monitoring

Your peak flow meter is often considered THE primary tool for to monitor your asthma. Yet, while most asthmatics have one, few use it. And, those who do use it, few of them use it correctly. I know this because I work with asthmatics and I ask.

Read my recent post from myasthmacentral.com and learn all you need to know about peak flow meters:

Your Peak Flow Meter Is An Important Tool
by Rick Frea Wednesday, December 09, 2009, @MyAsthmaCentral.com

If you're an asthmatic, chances are you have a peak flow meter somewhere in your possession. Or, if you don't, you might want to consider requesting one from your asthma doctor. A peak flow meter is one of the best tools ever invented for helping us asthmatics monitor our asthma at home.

The problem with peak flow meters is most asthmatics don't use them, or when they do they use them improperly. When I see these asthmatics in the ER, it's my job to educate them.

So, what is a peak flow meter? Why were you given one? How should it be used? Why do asthma experts think they are so important?

The U.S. Department of Health and Human Services (HHS) recommends in their asthma guidelines that every asthmatic work with his or her doctor to create an asthma action plan. This is a plan that helps you decide when to use your rescue medicine (like Albuterol), when to call your doctor, and when to have someone take you to the emergency room.

To help you decide what to do, the asthma guidelines recommend you either monitor your asthma symptoms, use your peak flow meter, or both. What you do depends on you, your asthma and your doctor. I wrote about asthma action plans here, and monitoring asthma signs and symptoms here, so in this post we'll tackle the importance of peak flow monitoring.

When I was a kid with hardluck asthma, my peak flow meter came in handy quite a few times. I say this because I was short of breath so often that I basically became tolerant to it. So, I had to use my peak flow meter as a tool to help me decide what to do.

As an adult my peak flow meter became less useful. It seems that whether my asthma is acting up or not, my peak flow values neither increase nor decrease. This is something unique to me. Still, I monitor my peak flows daily because you never know when it will come in handy.

The asthma guidelines recommend the following asthmatics use peak flow meters:

Moderate asthmatics: They are at increased risk over mild asthmatics

• Severe asthmatics: They are at highest risk exacerbations
• History: Patients who have a history of severe exacerbations
• Dyspnea intolerant: They poorly perceive airflow obstruction and worsening asthma
• Children: They have a harder time communicating how they feel, and this provides a good tool for parents to monitor their child's asthma.
• Personal preference: Some asthmatics prefer this method
• Doctor preference: Doctors can use this as a monitoring tool

A peak flow meter is a handy, easy-to-use, hand-held device that you blow into as hard as you can. It basically measures your peak expiratory flow rate (PEFR), or how much air you can blow out with maximum exhalation.

Because measurement of PEFR is dependent on your effort and technique, it's important you work with your doctor, nurse or respiratory therapist to make sure you are using it properly. To review proper peak flow technique, click

here.

Ideally, you can use your peak flow meter as part of your asthma action plan. According to National Jewish Health, the plan would work like this:

1. You blow into your peak flow meter every day for two weeks when you are feeling well. Whatever PEFR was your best, that one is considered your personal best.

2. You use your daily PEFR readings, along with your personal best, to help you decide what to do:

1. If your peak flow is less than 80% of your personal best, you take your rescue medication, then wait 20 to 30 minutes and check your peak flow again.

• 1 If your peak flow is not back above 80%, report this to your doctor.
• If your peak flow is back above 80%, re-check your peak flow about every 4 hours for a day or so. Call your doctor if you continue to need rescue medicine

2. If your peak flow is less than 60% consider this an emergency: Take your rescue medicine, and call your doctor or go to the emergency room right away.

It's really quite simple.

You should blow into your peak flow meter every day in the morning, and in the evening. This is important, because your peak flows may be normally lower in the morning. Then, if you notice your peak flows trending down, you can use this as an

early sign of an impending asthma attack, and you can act now to nip it in the bud.

Likewise, if you do need to make a visit to the ER or doctor's office, your doctor can use your personal best as an indicator of how well you are doing, whether you need another breathing treatment, or if you need to be admitted. This can save you a lot of time, and maybe even prevent you from needing to be admitted.

Also, your doctor can use your peak flow readings to monitor how well your treatment regimen is working, and as a "quantitative measurement" of how good or bad your asthma is doing.

So, even when you're feeling well, use your peak flow meter. Get it out of the box, out of the closet, dust it off, and place it next to your bed near your asthma diary to record the results. Then use it daily like the gallant asthmatic we're sure you are.

Note: The Asthma guidelines recommend all asthmatics either use symptoms monitoring or peak flow monitoring as part of their asthma action plan, or both. The guidelines note that both methods are equally effective.

A job well done is a job well done

Recently a code blue rang out over head, and the destination was OB. I swear I ran all the way from the RT Cave to OB in less than 15 seconds. And, yes, the adrenaline was flowing through my veins and I was even a bit shaky. I'm sorry, but even after 12 years on the job, this was the first time my neonatal resuscitation skills were needed.

I took over ventilations as soon as I got there while someone else did CPR. The doctor from ER showed up and immediately intubated the baby. He already had an umbilical art line in, so we we drew a gas and sent it to lab. Epi was given again and again and again. The heart came back, and then it faded, and then it came back and then it faded.

And while we held up strongly during the event, as soon as it was called several hours later the doctor slumped over the patient and said a long prayer. The rest of us stood by in utter disbelief that we had to whiteness this; in utter disbelief of what we had to do here at our small town hospital.

We prepare for this throughout the year hoping to never use these skills. We have to do special training to remind ourselves how to use these skills because we aren't a large hospital and we don't do this stuff on a regular basis. As I wrote above, this was my first in 12 years. And, except for the doctor and one nurse, it was the first neonatal code blue for all the rest of us.

Later I sat down to talk to the ER doctor who came up to help us. He said something along these lines, "When I arrived there you were bagging, another nurse was doing CPR, and every body else was just standing around. I think that you guys ought to be trained to do things better."

My jaw dropped. How could he say such a thing. Then my jaw dropped even lower when he said, "I hate having to go up to the floor at this hospital. Here I'm an ER doctor, and I have to go up and have my name put on a chart of a patient upstairs, so if there's a lawsuit my name is going to be in it."

How can you be so selfish? Is all I could think to say. Still riding on the rush, I couldn't let this slide. I had to defend my coworkers: "I think things went excellent up there. Considering that most of the people at that code never did that before, I thought things went awesome."

"Really, you thought that?"

"I have never left a code where I said to myself, 'Gee, Rick, I think everything went perfect.' I don't because there is always room for improvement. But considering the limited staff and the limited experience we have here, I think we did awesome."

Yet he continued to explain to me how there could be a lawsuit. I said, "Still, it's in your job description to help us. If there is a code blue you have to come, unless you're tied up with another more important situation. But I can't think of anything more pressing than a neonate that's not breathing. Can you?"

"Well, no," he said. Yet he spun off again on another rant about lawsuits. He's an awesome doctor, and I respect him deeply. I really do. And I understand where he's coming from. Yet sometimes it's best to do what's right now, do good charting, and worry about a lawsuit some other day.

Besides, all he did was put in the ETT and tried to save the baby's life. In fact, that's what we all did. Are we supposed to stand idly by and let a baby die because we might get sued. I don't think so.

In fact, I think we ought to make this RT Cave Rule #42:

RT Cave Rule #42: It's best to do what's right now, do good charting, and worry about a lawsuit some other day.

Dr's Creed: Bronchodilators now lowers Fever

The following might seem like nonsense to thinkers like you and me, but the Real Physician's Creed teaches doctors otherwise. Heed, what follows is surreptitious wisdom previously shared only with physicians.

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Section B7

A study performed by the Dr's Creed Association of America, and in association with the University of Michigan, provided a nearly conclusive conclusion that all post-operative patients that develop a fever should be provided with bronchodilator therapy.

The study included giving 2,000 post-operative patients at four key hospitals in the State of Michigan a bronchodilator if they developed a fever. Care providers for these patients eventually noted normal temps eventually, and the patients all eventually got better and were discharged.

Therefore, based on this study, we recommend all post-operative patients who develop a fever be given a bronchodilator.

Now, it has been noted that some respiratory therapists complain that a placebo of normal saline should have been given to 2,000 different post-operative patients who developed a fever to see if those patients would have eventually gone home too. Although we Docs know that would have been a wasted of time and money.

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Cord blood gases: Here's all you need to know

Every respiratory therapist dreads having to draw cord blood gases, and all OB nurses dread the circumstances that require them to be drawn. So, that said, what are the indications for drawing cord blood gases, what is the significance of drawing them, and why do we draw them in the first place?

Basically, the reason we draw cord blood gases is in case their is a lawsuit that might take place years down the road accusing the delivering doctor of causing an anoxic brain injury that resulted in diseases such as cerebral palsy.

The cord blood can prove that neurological deficits that develop in infants were caused by an anoxic brain injury that occurred after delivery or before delivery and was not the result of an anoxic episode at birth. The cord blood gas has been shown to be proof positive in about 80% of the cases (According to PubMed.com), and has in many cases cleared physicians from litigation.

A cord blood gas does not need to be drawn unless a baby is born has a low APGAR score within 5 minutes of delivery, such as a 3 or less. When the APGAR score is low a cord blood gas should automatically be drawn.

When we refer to cord blood we are referring to blood drawn from the placenta after delivery. If you look at a placental cord (see picture) you will see one large vein surrounded by two arteries that wrap around the vein.

According to PubMed.com, the Umbilical Vein delivers freshly oxygenated blood from the mom to the baby. Since an anoxic brain injury in baby in not likely to change the pH of the Umbilical Vein, this is not where you will want to draw a cord gas from.

The Umbilical Artery is where the baby's venous circulation dumps unoxygenated blood. This is blood that was on its way back to the mom's heart and lungs to pick up oxygen. Thus, when you draw a cord gas for litigation purposes you will want to draw from one of the two Umbilical Arteries.

Blood from the Umbilical Artery is called a Cord Arterial Blood Gas (CABG), and basically shows how the baby was doing prior to birth.

From this blood we want to watch for acidosis. Since anaerobic metabolism occurs during the absence of oxygen, the acid base balance (pH) of the baby's body increases due to increase in the amount of lactic acid produced. Therefore pH is the most important indicator in the CABG.

If the pH of the CABGis above 7.10, then we know that the baby was not hypoxic during the delivery, and if there was a hypoxic episode it occurred prior to the delivery process. It may have occurred weeks or months prior to birth, or it may have occured hours before birth. Either way, this proves the episode did not occur as a result of the delivery and should clear the physician of litigation.

If the pH is less than 7.10 the episode was more likely acute and the episode may have occurred during the delivery. If the pH is greater than 7.10, the episode typically occurred before the delivery.

According to obgyn.org, Some experts believe a pH of 7.0 with a significant metabolic component is a more significant sign of asphyxia at birth, and may lead to significant neurological dysfunction during life, or possibly even death.

Also according to obgy.org, "Even when this low pH threshold is used to define significant acidemia, most newborns in this category will be neurologically normal, with no apparent morbidity."

The baby's at greatest risk of anoxic brain injury are premature infants, according to obgyn.org. They are at higher risk of "intracranial hemorrhage and subsequent neurological dysfunction, such as cerebral palsy. Without umbilical cord blood gas analysis, these neurological complications could be incorrectly attributed to intrapartum or birth asphyxia, especially if the latter is solely based on APGAR scores. Normal umbilical cord blood values in the premature infant virtually eliminate the diagnosis of significant intrapartum hypoxia or birth asphyxia."

So, ideally, you will want the pH to be normal. If it is normal and there is an anoxic brain injury the doctor can prove by the CABG results that since the pH had time to return to normal the injury occurred prior to delivery and the injury did not occur as a result of delivery. If the pH less than 7.1 chances are the injury occurred during delivery.

Once a CABG has been drawn it can be set aside. Most studies now show that a CABG does not need to be placed on ice, and is good for up to an hour.

• pH: 7.28 (+/-.5)
• pCO2: 49 (+/-8)
• pO2: 18 (+/- 6.2)
• HCO3: 2.5-3.5
• BE: 10

Critical values that might show anoxic brain injury during birth (acidosis):

• pH less than 7.0
• CO2 greater than 50
• PO2 variable (remember this is the baby's venous blood, so the PO2 is relatively low)
• BE is normal or low (10 or less)

Critical values that might show injury due to metabolic cause:

• pH less low (less than 7.25, critical is 7.10 as mentioned above)
• PO2 less than 20
• CO2 is normal or high
• BE greater than 10 (Best indicator of metabolic cause

The following are conditions that would warrant a CABG:

• Any abnormality during delivery process
• Low 5 minutes APGAR score (less than 3)
• Any abnormality in patient condition that occurs within 1st 5 minutes after birth
• Premature birth
• Post term birth
• Meconium in amniotic fluid
• Intubation
• Positive pressure ventilation (Neo-puff or bag mask ventilation)
• Suctioning
• Cesarean-section
• Severe growth retardation
• abnormal fetal heart rate tracing
• maternal thyroid disease
• intrapartum fever
• multifetal gestation

The following are sources used for this post:

• OBGYN.org: Cord Blood Gases to Determine Umbilical Artery Acid Base Balance
• Umbilical Cord Blood Gas Analysis
• Cord blood analysis
• FamilyPracticeNotebook.com
• Tips for how to draw CABGs
• Umbilical cord blood gases: routine measurement may exonerate ob.gyns

What do parents need to know about asthma?

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: We just found out that our 2 year old son has asthma.We do not know anything about this condition

My humble answer: You've come to the right place. There are lots of materials here that should help you in your quest to learn more about asthma. Plus you can read shareposts from asthma experts like myself (I grew up with asthma, in fact, I was diagnosed when I was 2). We write about what it's like to live with asthma, our advice to asthmatics and parents like you, and share the latest wisdom we learn.

Here is some basic information about asthma. Follow the links as there are several pages.

Here and here are posts I wrote a while back with you in mind. This post here is good too.

You should be able to recognize the asthma symptoms so you can act.

Which asthma meds work best. Here's a good post. While this is written for adults, the basic information is the same. You should discuss with your child's pediatrician which asthma meds work best for him or her though.

You should work with your child's doctor to create an asthma action plan to help you decide what to do when you observe the early signs of asthma.

You should know your child's asthma triggers so you can help him or her avoid them, or work with his or her pediatrician to treat them.

This should get you started.

The thing about childhood asthma to keep in mind is there is still a lot about this disease we don't know. Yet, with a good asthma doctor, asthma trigger avoidance, well educated and observant parents (like you), every child asthmatic should be able to live a normal life.

Good luck. And if more questions arise, please feel free to ask.

Symbicort may be new asthma miracle drug

While the FDA is spending it's time recommending to doctors to get asthmatics off medicines like Advair and Symbicort once asthma is controlled, more common sense research seems to be looking in the opposite direction.

Read on, and decide for yourself if Symbicort might actually be the future asthma miracle asthma medicine

Symbicort May Offer New Option for Asthmatics
by Rick Frea Monday, February 22, 2010 @ MyAsthmaCentral.com

While it has not yet been approved in the United States, Symbicort may some day be available as a rescue inhaler as well as a preventative medicine. In this sense, it may be the dream inhaler we asthmatics have been yearning for.

In Europe, Australia, and recently Canada, Symbicort has been approved for this purpose. The program is called the SMART program, and you can read about it by clicking here.

According to asthmansw.org, SMART is an acronym for "Symbicort Maintenance And Reliever Therapy." The SMART program is explained here:

"It is a daily asthma management approach that allows you to use a single Symbicort inhaler as both a preventer and a reliever. Currently Symbicort is the only medication available for use as BOTH a maintenance preventer and reliever.

SMART works this way as it contains two different types of medicine in the same inhaler - a preventer (Pulmicort [Budesonide]) as the long-acting reliever which helps to control redness and swelling in the airways, and a reliever (Oxis [Eformoterol]) which can not only work quickly, but can also last a long time.

A person using the SMART approach to manage their asthma would take a maintenance dose of Symbicort, usually morning and night to maintain or establish asthma control AND they would also take additional inhalations of Symbicort as needed to relieve symptoms.

SMART is suitable for all people aged 12 years or older who are currently recommended to take combination medication for their asthma.

Symbicort has been available in Europe since since 2000, and was first made available in the U.S. in 2007 as a combination inhaler to compete with Advair (which presently is No. 1 in the U.S. market).

Symbicort works as a rescue inhaler because Formoterol starts to open the air passages in your lungs in two to three minutes as compared to 10 to 20 minutes for Serevent (the long acting bronchodilator in Advair).

Still, while it's approved as a rescue inhaler, the SMART programs limits the patient to eight puffs of Symbicort in any given day.

Likewise, it should always be used in concordance with an asthma doctor, and always as part of a physician directed asthma action plan like the ones linked to from this site.

By using Symbicort as a rescue inhaler, the asthmatic receives a boost of corticosteroid every time there is an asthma episode, instead of just using a rescue inhaler (like Albuterol). This basically allows the patient to increase his corticosteroid when he needs it, and decrease it when he's doing well. In this way the asthmatic has more control

Thus, "Studies have shown that people using Symbicort SMART - an additional way of taking the existing Symbicort inhaler - took no extra inhaled steroids and needed fewer oral steroids compared to traditional treatment methods. They also experienced fewer asthma attacks."

An Astra Zeneca sponsored study (the makers of Symbicort) noted the SMART program resulted in a 28 percent reduction in severe exacerbation compared to a regimine of using Symbicort twice a day while using something like Ventolin as a rescue inhaler in between.

According to this article at news-medical.net, researchers in the U.S. are reviewing data currently available and have "found no significant reduction in the number of asthma exacerbations that required hospitalization among the patients who used single inhaler therapy. However, the reviewers did find that fewer adults on single inhaler therapy had exacerbations needing a course of oral corticosteroids"

Researchers are also awaiting the results of five not yet to be released trials.

The pros of using Symbicort as a single inhaler are convenience, improved control, improved compliance, and that you will automatically be getting an additional boost of steroids right when you need it. This may especially benefit those who are compliant with their controller meds. (This asthma blogger does not like the SMART program).

A con of using Symbicort as a single inhaler is that for those who do not regularly use it, it usually takes two to three weeks for inhaled corticosteroids to start working, and therefore the added boost of corticosteroid may prove to be of no benefit.

So research is ongoing, and the debate, I am sure, will continue.

Whether the SMART program or something like it will ever be approved by the FDA is still open to debate. Yet if this is someday approved it will make available yet another alternative for physicians and asthmatics to try.

A great description of blunt doctors

I was called to do a STAT EKG (which didn't need to be stat, but that's beside the point). Even though it needed to be done so quickly, I was unable to get to the patient because the doctor was playing with the man's groin.

I watched as the urologist played with the man's catheter, while the nurse tried to assist him. The doctor was blunt and not particularly nice to the nurse. And I got the feeling the doctor also forgot he was working on a real live patient, and not motor in an engine.

The doctor said things like, "Well, why isn't this in your kit here?", "Where's the tape?", "Why is the tape on the floor? Come on!", " We need to be better at this!", "I need some gauze here!", "Come on! Come on!"

Anyway, I watched this procedure for quite some time. The nurse left the room once to get something while the doctor waited impatiently, and she smiled at me as she walked past me, and rolled her eyes too. She knew I knew the doctor was being ridiculous.

The patient was calm through this whole thing, and he said to the doc, "Normally I'd be embarrassed with my thing all exposed with all these people in the room. But for some reason I don't care."

"Well, we'll be done soon," The doctor said. "We just gotta get this done."

"No problem," the patient said.

Finally the nurse came back with another nurse. The rest of the procedure was finally finished, and I started my EKG.

As I did this, the patient said, "You know, I really like that doctor. I really trust him and I think he does a great job."

"Yep," I said, "He is a great doctor."

"The problem is, he has poor bedside manners."

"True, yet I think that comes with the territory."

"You know what it is," he said, "it's that he is brilliant. He's brilliant at what he does. What he doesn't realize," he paused a moment, perhaps drawing the best words from his brain, "is that we aren't brilliant at what he does. And he has trouble comprehending that. And, for that reason, he has poor bedside manners."

"Wow!" I said. "You hit the nail right on the head. I couldn't explain it better than that."

Even after dealing with doctors like that all the time, it's never easy keeping your mouth shut and not telling the doctor he's an ass. Yet, I have never heard anyone confront a blunt doctor in this way, and I hope I never do.