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Wednesday, December 17, 2008

Bronchospasms don't always wheeze

Here's what the Dr. Ordered: "treatment prn for wheezes." I thought "What if the patient is SOB and is not wheezing? Do we not give a treatment if the patient says he is tight?

When I was a kid a nurse refused to give me a treatment once because, "The wheeze is in your throat."

"But I'm tight," I argued, "I need a treatment."

"The wheeze is in your throat." She made me rest and drink warm water. You don't hear asthma experts recommending warm water anymore, but when I was a kid that was standard. The regime was: rest, drink warm water, and if you don't get better that way use your rescue inhaler.

Years later, as an adult, I went to the hospital and the doctor figured I didn't need a treatment because, "Your peekflow is 700. That's above normal for your age and height."

"Um," I gasped. "I need a treatment."

My point here is that one should not judge whether a bronchodilator breathing treatment is indicated based on a lung sounds or peek flow alone. A thorough assessment and q&a is the best method.

For some asthmatics, myself included, and other chronic lungers too, bronchospasm may be unique to the patient. Sometimes it's noisy, and sometimes bronchospasms don't talk at all. Sometimes they make the peek flow low, and sometimes it may actually get better or stay within personal best range.

For COPD patients, standard therapy recommends not using a peek flow meter at all, considering the PF reading may actually go down after the treatment, giving a false impression that the treatment made the patient worse.

The moral of this post is that the signs of asthma (or COPD) may often vary form person to person, and are not always textbook.

The RT, RN and DR must use common sense in determining the most appropriate means of helping a patient in need, and not simply rely on "is he wheezing? Is his PF low?"

And that, my friends, is the thought of the day.


Anonymous said...

yeah i agree it dont always wheeze. I can guarantee you this.

Anonymous said...

Oh, man, you're describing my kid exactly. You know how many times I've had someone say to me, "But she's not wheezing," and I respond, "I KNOW. She never does. Trust me on this."

Anyway, great post. :)

Unknown said...

Excellent post.

I concur. Rhoncus is the result of a narrowed or obstructed airway, and while this is part of the asthmatic response, it is important for RCPs, MDs, & RNs, as well as the general public, to be aware that it doesn't always occur during an attack.

Josh said...

This is why I sometimes hate reporting numbers. The clinical picture may not be reflected in the numbers from the spirometry. I've worked with some great docs who've written orders such as "Treatments as per RT". It's docs like this that recognize that we know what we're doing and are confident in our abilities and judgements. It's the others that bother me though. The kind described in the post. "Sorry, no treatment for you, your PF is great. Just slow down your breathing."

Rick Frea said...

Those are the doctors who have never been short of breath before.

Anonymous said...

I too am not a wheezer although my husband lovingly calls me such.

However, even when I feel tight, I usually rely on my peak flow to verify or dispute. I'm hearing you say tightness trumps peak flow. Hmmm...

On the upside, I'm grateful to have a doctor that knows when I'm too tight and treats the symtoms and not the numbers.

Anonymous said...

Treat the patient, not the disease. Well said.

Anonymous said...

I have seen it go the other way, too, where the RT refused to give nebs because of lack of wheezing.

It's pretty important for everyone in health care to realize... especially when dealing with chronic illness... that patients are dealing with these things day in and day out. They begin to know what works and what doesn't - where health care practitioners have missed things in the past, etc. That's the whole point of a history.

Anyway, something on the funny side of things. I saw a nurse's note that said,

"Non-audible wheezes noted."

Anonymous said...

I wish someone would teach this to the ER staff at my local hospital. About once a year I don't have wheezing but have a horrible cough where I can't catch my breath and start choking. My peak flow and pulse ox are usually normal but it feels like I can't pass any air. I have to fight to get treated in the asthma section of the ER and to get nebulizer treatments because they don't hear an audible wheeze. They'll write that I have poor coloring and a persistant cough but they still don't consider it a sign of asthma. Of course in that ER asthmatics are never seen by RT for treatments. RT does the treatments when you're admitted but downstairs they're done by the regular ER staff

Anonymous said...

throwing medication at symptoms without knowing the cause is not the answer. There are many thing that cause shortness of breath, wheezing, tightness,and cough that can not be helped with breathing medications and in fact may increase problems. I would hold true to the possibilty that if the medical advise is not to perform therapy that these things need to be considered in this decision. The treatment making you feel better may only be treating the psychological factor of the attack and not the root problem.

Anonymous said...

I'm glad to have found this. I have always had asthma, and until recently have usually had audible wheezing (sometimes even when I felt i was breathing fine). However, since I moved a year or so ago, I wheeze a lot less- and have a lot more trouble breathing. I've had people tell me I don't need to take my inhaler because I'm not wheezing, even though I'm so out of breath I can't even answer them. It's a relief to see this appears to be fairly common.