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Monday, June 18, 2018

Heart Failure: what causes it?

Heart failure is when the heart is too weak to pump blood through the body. It poops out. The patient becomes winded on exertion as the person's heart cannot keep up with demands on the body. So, what causes heart failure? Here's what to know.

1. Hypertension: Coronary artery disease is one ailment that causes blood vessels to become narrow. Years of working hard to pump blood through narrowed vessels can cause the heart to become hypertrophied (enlarged). A large bicep is good, and it's a sign of good health. A large heart is a sign of a weak pump. It is bad. Eventually, it will tire and become an ineffective pump. In fact, 60% of heart failure cases are the result of high systemic blood pressure and coronary artery disease.

2. Coronary Artery Disease (CAD): According to the National Heart, Lung and Blood Institute (NHLBI), CAD is a disease whereby plaque builds up inside the coronary arteries (arteries that supply oxygenated blood to the heart). This plaque buildup is called atherosclerosis, and will slowly cause these arteries to narrow, and thus force the heart to work harder to oxygenate itself. This can often lead to portions of plaque to break free, forming a clot in the heart, and causing a Myocardial Infarction, otherwise known as a heart attack (I'm sure you knew that, but just saying). 
3. Myocardial Infarction: This is where plaque from diseased coronary arteries breaks free and blocks blood flow to a part of the heart, causing heart (muscle) tissue in that area to die. This can cause heart failure. In fact, it can cause severe heart failure symptoms, including dyspnea, orthopnea, hypoxia, cyanosis, and even death.

4. Pulmonary Hypertension: This is where the pulmonary vascular resistance increases to a point where it causes the right heart to become hypertrophied. This makes the right heart a weaker pump. This often leads to left heart failure. Causes of this are COPD, cystic fibrosis, and pulmonary fibrosis. I go into more detail in my post, "Links Between COPD and Heart Failure."

5. Cor Pulmonale: This right heart hypertrophy. It means the right heart has become a weak, ineffective pump. This is responsible for 10-30% of admissions for CHF. For more detail, again check out, "Links Between COPD and Heart Failure."

6. Heart Disease: About 30-40% of heart failure is caused by heart disease.

7. Heart Valve Disease: This constitutes about 20% of heart failure. When the valves of the heart fail to work properly, this causes the heart to become a weaker pump.

8. Congenital Heart Defects: These are diseases a person is born with, and you can read about this in my post, "Congenital Heart Anomalies."

9. Drug abuse: Amphetamines, heroin, cocaine and other drugs may actually numb the heart so much that it becomes a less effective pump and ultimately fails.

10. Alcohol Abuse: Years of abusing your body can cause it.

11. Infection: Influenza, mumps, and rabies are infections that can stun the heart, as are various bacterial infections (streptococcal, rheumatic heart disease). Likewise, sepsis (a systemic blood infection) can also weaken the heart's ability to pump blood.

12. Other diseases: Leukemia, neurologic disorders (Duchenne's muscular dystrophy, Multi-system organ failure, Sepsis, Trauma, cardiac tamponade (squeezes the heart), diabetes and obesity. Diseases such as hemochromatosis or amyloidosis that cause the heart to stiffen, thus decreasing the heart's ability to relax.

All of the above can cause the heart to become a weaker pump, thus resulting in a loss of cardiac output, and causing pulmonary edema and other symptoms that mimic asthma.

Monday, June 11, 2018

All that wheezes is asthma

It's asthma even if it's heart failure.
So, it was so long ago. It was in 1998. I was called to a room. The patient was extremely short of breath. The patient was winded. She was sitting in the recliner all frogged up. She was blue. Her saturation was 77%.

The nurse said, "She just went to the commode and she got like this." 

I was a new RT. I was stressed. What do I do?

Thankfully, a senior RT came to the rescue. She smoothly investigated the situation. She said, "What are the patients i's and o's." It was the first time I heard that question asked.

The  nurse said, "I don't know?"

The RT bluntly said, "I think we should check."

Later she said to me, "Sadly, RTs are the only people who ever check the i's and o's." Twenty years later, when I found myself the seasoned RT, I found myself saying the same thing to a new RT. Go figure! Twenty years on this job and not much has changed.

So, anyway, this seasoned RT gave the treatment. The patient's sats increased to 98% during the treatment. But, as soon as the treatment ended, and the patient was back on 2lpm nasal cannula (back then you didn't dare increase the flow rate without first asking the doctor's permission), her sat went back down to the mid 80s.

So, the therapist did the only logical thing. She started the treatment back up. Only this time there was no medicine. She later told me she did this to save the life of the patient. She knew the patient needed oxygen. She knew what was wrong with the patient: She needed oxygen. She also needed something other than the albuterol. She needed medicine to treat heart failure.

So, I saw this one time and I knew and I learned. I saw this one time. And, you would be amazed at how often this happens in the hospital setting. The patient uses the commode, gets winded, and RT is called to give a breathing treatment. The patient gets fluid overloaded, RT is called to give a breathing treatment.

I find that respiratory therapist learn. I feel I don't need to educate RTs about this. The people I would like to educate are the doctors and nurses. But, how do you do that without offending people?

So, that's the state of the medical profession today. Actually, it's no different than it ever has been. Medicine is based on myths, and myths prevail to this day. And one myth is that all shortness of breath is cured with asthma medicine. The myth is all that wheezes is asthma. And this may never change in an ever-present dogmatic medical world we live in.

Monday, June 4, 2018

Cardiac Asthma Treated As Asthma

So often respiratory therapists are required to give breathing treatments to patients presenting with dyspnea and wheezing. This is fine and dandy if it's asthma. But, when it's heart failure (a.ka. cardiac asthma), a bronchodilator isn't going to work. The treatment is something else, totally.

But, because we are good RTs, we do the treatment anyway. And, while the treatment is going, we investigate the patient's chart. We often begin and end with the i's and o's (ins and outs). It ends if we determine the patients I's are way more than the O's. This means the patient is probably wet. And it means that it's probably not bronchospasm and shouldn't be treated as such.

As we just proved once again, among the most common reasons for this failure is a misdiagnosis of asthma when the primary cause of symptoms is actually heart failure.

So, that said, the RT Cave participated in an unofficial poll of 2,000 respiratory therapists. Nearly 80% of them said that the most common symptom of heart failure is forced and audible expiratory upper airway wheeze. It's often loud enough that you can hear it from the door.

Likewise, this same group of therapists said that this describes 80% of the breathing treatments they do in emergency rooms. A patient presents to the ER with shortness of breath and an audible wheeze. Among the doctor and nurse community, this is immediate confirmation of the need for RT services. Yes! A breathing treatment is ordered. And RT is paged. Often we are paged STAT!

This also happens on the floors. You are the therapist on duty and you get called STAT! to do a breathing treatment on a patient presenting with dyspnea. Upon your assessment, you learn the patient was fine until she went to use the commode.

You realize right away that it is not asthma or COPD causing this flare-up. It's heart failure. The patient's heart is too pooped to make the journey. So, the patient gets extremely winded. The patient might even turn blue. Their sats may drop into the 70s. And, to some nurses and doctors (and probably some RTs too), this is an immediate indication for a bronchodilator breathing treatment. RT is called STAT!

So you, the lowly therapist with a lowly associate's degree, diagnose the patient with heart failure. Well, we don't diagnose, but you get the picture. And so, you start the breathing treatment. You give the treatment from an oxygen 50 PSI source. The estimated Fio2 is 60% during breathing treatments. The patient's oxygen saturation shoots right up.


The patient is suddenly no longer dyspneic. You get credit for fixing the patient. The RN and patient and doctor see the nebulizer. They see the patient is feeling better after all. So, the only logical reason for this to them is that it was the treatment that helped. The cause was asthma or COPD.

Well, no!


It was not asthma or COPD. It was the oxygen boost that helped the patient. It was rest that fixed the patient. It was NOT the bronchodilator. It was not the albuterol. It was not the atrovent. In fact, more often than not, the patient is already fine by the time RT arrives.

But, this is how myths get born.

It was not the albuterol, dummy! It was the oxygen. It was the rest. But, I think most of us gave up long ago educating about this. We just apathetically do the treatment and go about our business. We are very professional in this way.

Sunday, May 27, 2018

RT Cave Rule: Sats low? Check the tubing first

So, I was called stat to the emergency room. I was told to give a breathing treatment to the lady in room 221. She was in severe respiratory distress.

I opened the door to her room. She was sitting there blue and puffing. But, I watched as the nurse disconnected her from her home concentrator and hooked her nasal cannula up to the wall

She continued to be blue and winded. She was a happy little lady, though. She never stopped chatting, despite the fact she was pretty winded. And she started talking about her cats. Oh, how she loved her cats.

And so I checked her nasal cannula. It had holes in it. She said, "My cats got into my oxygen tubing. And I didn't have any replacement tubing."

From the cabinet, in the room, I grabbed a new nasal cannula. I took her off of her cannula. I put the new cannula on her. And, lo and behold, her pulse oximeter reading perked right up to 92%. She was also no longer blue.

Of course, I still have to give her that breathing treatment. But, by the time I started it she was feeling fine.

Labs were later drawn. An x-ray was taken. And they were both normal for her. So, the doctor discharged her and we sent her on her way.

The discharge diagnosis: Catsma.

So, we will make this RT Cave Rule #62. If the patient's blue with low sats, check the tubing first.

Thursday, April 12, 2018

A Conversation With My Son

So, this is not respiratory therapy related. But, we all have families. And we all enjoy kids. So, here's a little conversation I had with my 7 YO a few days ago.

Son: "Dad, what does the F-word mean?"

Oh, keep in mind I have a teenage daughter. And my son will not say these words. He will only refer to them.

I said, "Ummmmm"

While I scratched my head in search of a good answer, he spared me. He said, "Does it have something to do with the S-word?"

"What S-Word?" I asked.

He sad, "You know: S-E-X."

I did not answer. After a short pause, he said.

"Say it day. Say the s-word."

"I said, "The s-word."

"No, say the actual s-word."

"The actual s-word."

"No. Say S-E-X."


"Dad, just say the word," he continued on, calmly, cooly.

"Fine," I said, "Sex." Pause for effect. Then I bravely added a question. I asked, "What does sex mean, anyway?"

He smiled, and said, "You know, it's short for sexy."

Monday, January 8, 2018

I won't remember you

"Hi, John! "How's it going?" The person says. I'm at Walmart. My mind races to find the gray matter where in my mind that brings forth a memory of this person. Nothing!

"Hi," I say, "How are you doing?"

"Great!" The person says."  Then she starts talking to me as though I know who she is and what she's talking about.

I am so guilty of this. My favorite part of my job is having conversations with patients. I've discussed many of these discussions on this blog. I am so willing to talk about God and politics even. I mean, you do so appropriately. But I have had such deep conversations with people.

So, this person is probably one of them. But there's so many of them. There's no way I can remember them all.

My wife remembers all her patients. She knows them all when she sees them. If she wanted to, if it weren't for HIPPA, she could entertain me with stories about people she meets. But not me. I don't remember.

That's just me. I just don't remember.

And it doesn't matter if you are readmitted to the hospital or if I meet you at Walmart. And it's even harder at Walmart because you won't have a robe on. There's a chance I might have a flashback if you have a robe on.

Monday, December 18, 2017

The Best Christmas Gift Is Time

A week before Christmas every year we walked across the street to the nursing home. This would have been in the 1970s. I would have been seven, eight, and nine. This would have been on Monday nights. That’s when we had Catechism classes at Manistee Catholic Central.

So, here it was December 1976. We were all to bring in some gift. My mom bought me a handkerchief. So, that was my gift. It seemed like a stupid gift. But I wrapped it as awkwardly as a seven-year-old might do this. I walked my gift with my class across the street.

My teacher opened the door to the nursing home. The redolent smell of bleach and urine. It was an old building, so there was also that old musty smell old buildings have. Back in 19th century, up until 1970, it was a hospital. It was Mercy Hospital. My grandma said it was one of the most beautiful hospitals. It had a huge Church cathedral in the middle. They tore the Church down left the rest to become this nursing home.

Immediately we saw old people. There was a crooked old man. There was another man who made awkward movements with his face. Another who made awkward gestures and movements with his entire body. There was another who was in a wheelchair and breathing funny. They were all looking at us. They all seemed to be happy.

Our group was split up into small groups. My group was introduced to a group of very, very old men sitting at a poker table. And I was introduced to one old man. He looked very plain. He had greasy hair and glasses. He wore a plaid button-down shirt. In the shirt pocket was a white hanky.

My teacher said, “This is your buddy."

My buddy awkwardly smiled.

I awkwardly handed my buddy my gift.

As a typical 7-year-old, I was quite taciturn around strangers.

The old man asked me questions. “So, how old are you?”,

“Seve,.” I said, after a long delay.

“How do you like Catechism?”

“It’s okay.”

“What do you want to be when you grow up?”

“I don’t know.”

“Do you like firetrucks?”


“I used to be a fireman.” His smile grew. “It was a fun job.

I said nothing. I looked at the ground. I looked at my shoes.

“Do you want to be a fireman, you think?”


“This is a nice wrapping job,” he said. I looked up and watched as he opened it.

“This will come in handy,” he said, pulling out the white hanky.  He pulled the old hanky out of his pocket. He set it on the table. He folded my hanky. I was impressed at how neatly he folded it. He put it in his shirt pocket so just the top was shown. He patted it slightly. He looked down at me. He smiled.

“This will do just great,” he said. He patted me on the head.

My teacher said it was time to leave. I left the nursing home with my class. We crossed the highway. We wenttoo the school. We walked down the hallway to our classroom. I satatn my desk. When we were all seated, the teacher walked up to me. I looked up at him.

“How did your buddy like your gift.”

“I guess… he liked it.”

“What was your gift.”

“A stupid hanky.”

“That was a nice gift,” my teacher said. “But he didn’t care about that hanky.”

“He loved it, he said," I said.

“Really?" She smiled awkwardly. Then she added, “But that’s not what made him smile.”

I said nothing.

“What made him smile was YOU. You were God’s gift to him."

“What do you mean?” I asked.

“Sometimes, the greatest gift of all is the gift of time spent with someone.”

I think all of us in healthcare realize this eventually.