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Sunday, July 6, 2008

SOB is not always caused by bronchospasm

So long as there are doctors who think that a bronchodilator treatment will cure everything that causes shortness-of-breath, there will always be frustrated RTs.

As long as their are doctors who believe that all adventitious lung sounds are an indication for a bronchodilator, there will be frustrated RTs.

Let's make this simple, and get right to our next RT Cave Rule:

RT Cave Rule #22: Everything that cause shortness-of-breath does not get fixed with a bronchodilator. Bronchodilators relax the smooth muscles of the bronchioles, and thus treat bronchospasm only.

RT Cave Rule #23: All adventitious lung sounds are not an indication for a bronchodilator.

That in mind, I have a few case studies here. I would like you to answer three questions for each case study: 1) What is your initial impression of the patient, or what do you think is wrong? 2) Would you recommend a bronchodilator and why? If yes, what frequency? 3) What do you think the doctor actually ordered?

I'll put the answers below, don't peek.

#1: You are doing an EKG on a patient who says he is mild SOB, but feels much better once he is on 2lpm nasal cannula. You notice he has the cardiac scar. After you finish the treatment, you learn by auscultation he has crackles 1/2 way up.

#2: You are doing an EKG, and you ask the patient if he is having any shortness-of-breath or chest pain. He says, "No. I'm having bad back pain." Upon auscultation you learn the patient has crackles in the left lower lobe. He then reveals that he does have pain with deep inspiration.

#3: You are called STAT to ER for a patient in severe respiratory distress. He has been a 3 pack a day smoker since he was 7, and he's 77. His ABGs are cruddy, and reveal severe acidosis. You look up on the monitor and see the prototypical fireman's helmet on the rhythm strip. This is verified by an EKG.

#4: You have a patient who has asthma and he smokes. He states that he is mild sob.

Here is how the above cases turned out:

#1: The patient has obvious signs of CHF. No breathing treatment indicated. If the patient is wet, you don't want to put more fluid into his lungs. The patient should be treated for suspected CHF, with some Lasix perhaps. Along with diagnosing and treating the CHF, the doctor ordered Q1 hour bronchodilator.

#2: I surmised the patient had pneumonia of the left lower lobe. I would recommend no breathing treatment because the patient is not SOB and shows no signs of bronchospasm. The doctor diagnosed the patient with pleurisy. She diagnosed this way because "the x-ray showed no pneumonia, and his labs are normal." Still, I think this guy has pneumonia, but that's just my humble guess. Either way, a bronchodilator doesn't treat inflammation. Still, a Q1 hour bronchodilator was ordered. The patient noted no difference with any of them.

#3: The pt is labored secondary to having an MI. The patient needs to be intubated. The doctor eventually intubated the patient, but only after an hour long continuous bronchodilator treatment was finished with no results.

#4: This patient has a good chance of bronchospasm. A bronchodilator is indicated because bronchodilators treat bronchospasm. The patient was diagnosed with asthma attack. The treatment really opened the patient up, and a second one was probably warranted. The doctor ordered a one time breathing treatment. A second treatment was never ordered on this patient who actually could have benefited from a second one.

So, how did you do. I bet you did pretty well.

Personally, I think it is fine to try a bronchodilator on all these patients, because there's always a possibility there might be a bronchospasm component. The ordering of further treatments should be based on assessment.

But that's just me.

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