Occupational Asthma

So you're an adult and all of a sudden you develop asthma. Perhaps it was caused by your work. If so, you have occupational asthma.

For more information, read my latest post from MyAsthmaCentral.com

Occupational Asthma: Your Work Caused It

You could be 30 or 40 years old and still not show symptoms of asthma. Yet gradually your lungs are changing, and the cause is related to your work. Now you have asthma, and all symptoms that go with it.

What I'm describing here is one of the more recently defined types of asthma called Occupational Asthma.

The theory here is that, according to the Mayo Clinic, if you have the asthma/ allergy gene, and you are exposed to certain irritants and allergens in the workplace, over time, these certain irritants may actually irritate the air passages of your lungs and make them more sensitive to these allergens.

The Mayo Clinic also notes that constant exposure to certain allergens can cause your body to develop a sensitivity (allergy) to it. Your body identifies the substance as a "threat" and later exposed will cause your body to attack it. During the attack your body releases chemicals like histamine, which cause inflammation of the lungs.

According to the Mayo Clinic, long-term exposure to any of the following may increase your risk of getting asthma:

• Animal substances, such as proteins found in dander, hair, scales, fur, saliva and body wastes.


• Chemicals, such as anhydrides, diisocyanates and acids used to make paints, varnishes, adhesives, laminates and soldering resin. Other examples include chemicals used to make insulation, packaging materials, and foam mattresses and upholstery.


• Enzymes used in detergents, flour conditioners, some pharmaceuticals and meat tenderizers.


• Metals, particularly platinum, chromium and nickel sulfate.


• Plant substances, including proteins found in natural rubber latex, flour, cereals, cotton, flax, hemp, rye, wheat and papain, a digestive enzyme derived from papaya.


• Respiratory irritants, such as chlorine gas, sulfur dioxide and smoke.


• 2nd hand smoke: Click here to learn how your co-workers cigarette smoke can cause asthma.


• Strong smells: Heavily scented cologne and perfume


• High or low humidity: Click here to learn these are both linked to asthma


• Hot or cold air: Extremes in weather can trigger or cause asthma as you can read here.


• Physical exertion: Click here to learn why some athletes are at increased risk for developing exercise induced bronchospasm.

According to the American Accedemy of Allergy, Asthma and Immunology (AAAAI.org) as many as 15 percent of asthmatics in the U.S. have occupational asthma.

Bakers commonly develop allergic asthma from breathing in flower and cereal grains. About 5 percent of those working with lab animals or latex gloves develop allergic asthma. Another 10 percent are those exposed to chemicals from spray painting, insulation, rubber and foam.

Others at high risk include (according to Mayo clinic): janitors and hair dressers due to sprays, healthcare workers due to latex exposure (although many hospitals now use non-latex products), adhesive handlers (chemicals), pharmacists (drugs and enzymes), carpenters (wood dust), solderers (metals), and textile workers (dyes).

Symptoms of occupational asthma are the same as asthma in general, which (as you can read here) include wheezing, coughing, chest tightness, shortness of breath, runny nose, nasal congestion, and eye irritation.

Testing by a qualified asthma doctor and a question and answer session can make the asthma diagnosis. Questions you may be asked are:

• Did your symptoms start after you were hired at a certain job?


• Did your co-workers likewise get diagnosed with asthma?


• Did symptoms start after high exposure to certain chemical at work?


• Do symptoms improve when not at work, or on vacations?

The thing to keep in mind here is that if asthma runs in your family you are at increased risk, and it's important you try to avoid jobs that put you at risk of inhaling the above mentioned allergens or irritants. If you're already diagnosed with asthma, the same holds true.

If you're diagnosed with occupational asthma, it can be controlled by finding a good asthma doctor, and working with that doctor to create a good asthma action plan, avoidance of your asthma triggers (in this case certain workplace allergens and irritants), and finding a good medicine regime and sticking to it like a gallant asthmatic.

With good asthma control, many asthmatics can continue doing the jobs they love. Although others may be forced to make a career change.

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Dear Doctors: Don't be callous

I knew what would benefit the patient, and the doctor Mallison was sitting right next to me, yet I said nothing. I knew I had a 50/50 chance this doctor was going to say something like, "Rick, we are not going to extubate this patient!"

Better yet, the other day Dr. Peterson was sitting at the desk charting, and Dr. Mallison came up to him and said, "Why didn't you order ventilator protocol! You need to order ventilator protocol! I see there was no sputum sample either. If you would have ordered the protocol this wouldn't have happened!"

Dr. Mallison walked out of the room. That was when Dr. Peterson spoke for the first time, "What does she think she is: the chart police. There's no law that says I have to order the ventilator protocol."

Dr. Mallison is like a ticking time bomb. She has absolutely no empathy for the fact that you are at the bedside and might know what's going on with the patient at that moment either.

One time I had a patient who's sats were in the 70s and increased the oxygen to a 50% ventimask, and then I called the doctor. My thinking was that if I didn't take this action in this order, the patient would be dead by the time the doctor answered her page.

It's common sense. Right?

Yet Dr. Mallison laid into me: "Why do you raise oxygen without an order. What if she was a retainer? You should know better than to raise oxygen without an order!"

So you can see, she's a hard liner. So here I was, sitting next to her with my ideas for helping the patient, yet I was afraid to ask her.

Later that night the nurse had a concern and wanted to call the doctor. Normally she would have picked up the phone and called, yet she turned to me and said, "I don't want to talk to her. She'll say something like, "Why are you calling me at 2 in the morning."

Callousness is a trait that no doctor should have. To have no empathy and show no respect for other doctors, nurses and respiratory therapists only results in worse patient care.

Taste receptors in lungs may benefit asthma???

Believe it or not, taste receptors (as reported at BBC news) have been found in the lungs. It has also been determined by scientists that they are receptive to bitter tastes, and this might just benefit the 300 million people worldwide with asthma and COPD.

Stephen Pincock for ABC Science Online:

The receptors are the same as those that cluster together as taste-buds on our tongue, Deepak Deshpande from the University of Maryland and colleagues reported in the journal Nature Medicine.

In experiments using human and mouse lung tissue and mice with asthma, they found stimulating these receptors in the lungs with bitter substances decreased airway obstruction.

In fact, co-author of the study, Stephen Liggett, noted that the bronchodilating for this type of therapy was greater than bronchodilatinig effect of any medicine currently on the market for asthma and COPD.

It should be known, however, that taste receptors in other parts of the body other than the tongue will not help YOU taste things better. It more that they are responsive to bitter substances, and the response may help or hinder the treatment of various diseases.

Initially scientists believed the response to lung taste receptors would cause the "flight or fight" response where the lungs would respond to stimuli such as strong smells by causing bronchoconstriction, yet that did not turn out to be the case.

In this regard, these findings and test results came as a complete surprise to scientists doing the research. Likewise this new information is surprising to we asthmatics and COPDers as well, especially if a newer and better asthma therapy is the result.

Sorry, eating bitter foods will not cause bronchodilation. However, scientists believe certain inhaled, bitter aerosolized medication just might some day help open up the lungs.

Sarcoidosis

Another disease we RTs see from time to time in the hospital setting is Sarcoidosis. This seems to be a relatively mild disease, although occasionally it can lead to symptoms and a need for a recharge in the hospital requiring the services of a respiratory therapist.

According to the Mayo Clinic it's "characterized by the development and growth of tiny clumps of inflammatory cells in different areas of your body — most commonly the lungs, lymph nodes, eyes and skin." However, it may also effect the liver, brain and heart, thus resulting in more severe complications.

The cause is relatively unknown, although it's believed the body has a normal immune response to something inhaled, such as a bacteria, virus, dust or even chemicals (perhaps some chemical inhaled at work). The immune system triggers a natural response that causes inflammation, and yet this inflammation does not go away.

Instead, as noted at the National Heart Lung and Blood Institute (NHLBI), "some of the immune system cells cluster to form lumps called granulomas in various organs."

Since granulomas in an organ can effect how it works, signs and symptoms will depend on the organ effected, and treatment will depend on the organ effected and the severity of the symptoms.

Most (or about two-thirds) with the condition have no symptoms at all or mild symptoms, and the course of their disease is relatively mild. Yet when symptoms are bothersome, or if an organ is at risk, treatment treatment with anti-inflammatory medication will be needed, according to the Mayo Clinic.

Medlineplus notes that while the course of the disease is generally mild, "it can be severe and do lasting damage." For example, as the Mayo Clinic notes, "Untreated pulmonary sarcoidosis can lead to irreversible damage to the tissue between the air sacs in your lungs, making it difficult to breathe."

In effect, according to the Mayo Clinic, in some rare cases, Sarcoidosis may lead to...

1. Interstitial lung disease (ILD), which is ultimately pulmonary fibrosis.
2. Inflammation of the eyes can cause cataracts, glaucoma or even blindness.
3. Kidney failure as granulomas effect how the body handles calcium
4. Abnormal heart rhythms that can be life threatening because granulomas can effect the electrical conductivity of the heart
5. Facial paralysis due to electrical impulses in the spinal cord and brain
6. Infertility in men if it infests the testes
   

So what is the cause of this disease and who is at risk? According to the Mayo Clinic, NHBLI, and Medline Plus, the cause is relatively unknown, and the gene has yet to be isolated.

However, the Mayo Clinic notes that while anyone can get Sarcoidosis, the risk of getting it is increased in:

• You are between the ages of 20 and 40
• Women slightly more than men (may be more severe in blacks & result in skin problems)
  
• Blacks slightly more than whites
• Families originally from Northern Europe — particularly Scandinavia and Britain. (People with Japanese ancestry are more likely to develop eye or cardiac complications)

Symptoms vary from patient to patient, vary based on the organs effected and length of time the person has had the disease.

As noted above, symptoms are generally mild vary based on the organ and length of time the person has had the disease.

The Mayo Clinic notes that, "Sometimes sarcoidosis develops gradually and produces signs and symptoms that last for years. Or symptoms may appear suddenly and then disappear just as quickly. Many people with sarcoidosis have no symptoms, so the disease may not be discovered until you have a chest X-ray for another reason."

According to the Mayo Clinic, some of the early signs include:

• Fatigue
• Fever
• Swollen lymph nodes
• Weight loss

Most will eventually develop lung problems, and the symptoms will include:

• Persistent dry cough
• Shortness of breath
• Wheezing
• Chest pain

Those with skin involvement may develop a rash, nodules (growths just under the skin), areas of skin may get darker, or disfiguring skin sores on nose, cheeks and ears.

Eye involvement may include blurred vision, eye pain, severe redness and sensitivity to light.

By the time a respiratory therapist is called upon to treat someone with this disease there is lung involvement.

NHLBI notes another classic symptoms is Lofgren's syndrome. This "is a classic set of signs and symptoms that... may cause fever, enlarged lymph nodes, arthritis (usually in the ankles), and/or erythema nodosum... (which is) a rash of red or reddish-purple bumps on... ankles and shins. The rash may be warm and tender to the touch."

Diagnosis usually involves:

• Chest x-ray: will show enlarged lymph nodes or any related lung damage, such as fibrosis of lung tissue or air trapping.
• CT Scan: Provides a more detailed picture
• Lab tests: To check for liver or kidney function (damage)
• Biopsies: Tissue taken from infected areas can be tested for types of granulomas. Lung biopsies are taken from bronchoscopy

Treatment, according to the Mayo Clinic, is usually reserved for those who show symptoms, and includes:

• Corticosteroids: Creams can be applied to affected areas, and inhaled corticosteroids or systemic corticosteroids can be used to treat those with infected lungs to treat inflammation. A first line medicine.
• Anti-rejection meds: Drugs methotrexate (Trexall) or azathioprine (Imuran) reduce inflammation by suppressing your immune system. These are 2nd line therapies, and carry risk of inceasing infections.
• Anti-malarial drugs: Hydroxychloroquine (Plaquenil) may be helpful for skin disease, nervous system involvement and elevated blood-calcium levels. May cause eye problems.
• TNF-alpha inhibitors: Tumor necrosis factor-alpha (TNF-alpha) inhibitors are most commonly used to treat the inflammation associated with rheumatoid arthritis. Some studies have indicated that infliximab (Remicade) is also helpful in treating sarcoidosis. Potential side effects include congestive heart failure, blood disorders and lymphoma.
• Organ transplant: Rare

The Mayo Clinic notes that in most cases where the patient shows symptoms, the symptoms go away with treatment, and usually completely resolves within a year or two. About 50% of cases go into remission within three years..

However, in some cases, permanant damage is done to the organ, such as untreated pulmonary granulomas can result in pulmonary fibrosis, heart granulomas can result in cardiac arrhythmias

Like COPD patients, or those with severe asthma, patients with the severe forms of the disease will need to make lifestyle changes and may require counseling, pulmonary rehabilitation and counseling.

Neonates should be kept warm

We had 6 day old neonate present to the emergency room in respiratory distress. When I arrived on the scene I saw a baby lying limp on the ER bed. The first thing I said was, "We need to warm that baby up."

One of the nurses proceeded to get a warm blanket, while another went up to OB to get an incubator. Within moments of being warmed the baby's respiratory rate improved, and muscle tone was much improved.

The moral of this story is one of the first things to think of when you have a neonate is to make sure it is warm. Ideally you will want a core temperature between 36.5 and 37.5 degrees celcius.

You may not think of this, but you have heat and cold receptors in your skin deep in the tissue, which send signals to the hypothalamus in the brain to release norepinepherine, which start a cascade of events.

According to S.T.A.B.L.E Program, "In response to cold stress, a series of reactions are activated for the purpose of decreasing heat loss and increasing heat production These include constriction of blood vessels in the arms and legs, increased muscle flexion activity, and metabolism of brown fat. To mount these responses, the metabolic rate must increase which, in turn, increases utilization of both oxygen and glucose."

Vasoconstriction: This prevents blood from reaching the skin to keep vital organs warm. If prolonged, oxygen delivery to the skin is prevented.

Increased muscle activity and flexion: Infants do not shiver. Instead they cry and move around to keep warm. This also reduces surface area for heat loss. If a child is flaccid, heat loss is increased due to increased surface area.

Brown fat metabolism: 6-8% of infants body weight consists of brown fat, which can be burned to create heat. Brown fat exists around vital organs such as the kidneys, adrenal glands, mediastinum, subscapular and axillary regions and the nape of the neck. When signaled to burn, brown fat creates more energy than any other tissue in the body to produce heat. This is actually called "non-shivering thermogenesis."

If cold stress gets bad enough, this can lead to pulmonary vasoconstriction, which can lead to a right to left shunt of blood through the foraman ovale and the ductus arteriosis, which can actually lead to persistent pulmonary hypertenstion and hypoxemia. The child will ultimately decrease it's respiratory rate and become flacid.

Mechanism of heat loss:

1. Conductive: This is heat loss that involves the transfer of heat between two solid surfaces, such as a metal surface the baby is set on, or cold stethoscopes, x-ray plates, blankets, your hands. These things should all be pre-warmed.

2. Convection: This is heat loss that occurs as a result of air currents, such as air conditioners, windows, drafts from air vents, or lab coats. This is why it's important to make sure the air is warm before baby is born, and limit anything that might cause a cold breeze, such as lab coats. It's also important to warm and humidify oxygen to an infant.

3. Evaporative: Occurs when moisture on the skin surface or respiratory tract mucosa is converted into vapor. The process of evaporation is always accompanies by a cooling effect. This is why it's important to dry infants with a warm towel and immediately remove wet linens.

4. Radient Heat Loss: This is heat loss by transfer of heat between solid surfaces that are not in contact with each other. The infant's skin temp is usually warmer than surrounding surfaces, so the direction of heat transfer will be from the exposed parts of the infant's body to the adjacent solid surfaces. The cooler those surfaces, the greater the heat loss. Examples include cold windows.

5. Radient Heat Gain: Just for the sake of it, a child can also pick up heat from distant objects, such as the sun poking through the window, or an incubator that's set too high.

Preterm infants actually become hypothermic faster than term babies due to larger surface area, thinner and immature skin, decreased amounts of brown fat, poor muscle tone, and poor ability to vasoconstrict. Premature infants should be placed in an incubator and wrapped in polyethylene (plastic) from neck to feet to reduce evaporative and convective heat loss.

Temperature of neonates, particularly premature neonates, should be monitored closely.

Does it matter what inhaled steroid we use???

A new study published in the Journal of Allergy and Clinical Immunology and reported on here might prove that it does matter what inhaled corticosteroid a doctor prescribes to control your asthma.

The study, performed by General Practise Research Database (GPRD) studied 2,000 individuals with asthma, and compared the performance of QVAR and Flovent in the United Kingdom for one year.

The study "revealed that those treated with QVAR™ either as initial therapy or with an increase or step-up in dose had a similar or better chance of achieving asthma control than patients who were treated with fluticasone. Asthma control was achieved in the QVAR™ population at lower doses of drug versus those in the fluticasone population. The full article is available at www.jacionline.org/inpress."

GPRD is a not for profit organization, and I have found no evidence that the makers of QVAR (Graceway Pharmaceuticals) had anything to do with the funding of this study. If you know otherwise leave a note in the comments below.

This might be significant research, since recently (as I wrote about here) we in the asthma community have discussed the "theory" that QVAR might have a particle size that reaches deeper into the lungs, way down to the smaller air passages. This may be the reason for the better asthma control.

So if you're having trouble gaining control of your asthma on Flovent, or Advair, or even Pulmicort, you might want to discuss with your physician the possibility of trialing QVAR either instead of your current medicine, or in conjunction with it.

Advair and weight gain: is there a link?

So the debate goes on. You've noticed bruising on your legs that don't go away, and you've gained weight since you started using it. Yet they say it can't be the new medicine. So the question is: Does Advair Cause Weight Gain?

Here's my take on this very common concern in a recent post at MyAsthmaCentral.com

Does Advair Cause Weight Gain?

Weight gain while using Advair is something that has been discussed a lot in asthma communities, as you can see here and here and here and here and here and here. Yet there has been very little documented evidence as to whether it is true or not.

I was recently asked, "Does Advair cause weight gain?" My answer here was a swift, "Studies have shown that if you rinse your mouth out really well after using your Advair inhaler systemic side effects are very rare."

Yet considering the broad discussions on this topic, I'm now wondering if my answer was, perhaps, not quite complete. Is it possible that Advair does cause weight gain, even with a good mouth rinse?

The answer: it's possible.

Asthma.emedtv.com notes that while weight gain was not listed among the side effects of Advair during initial testing; many asthmatics on Advair have noted weight gain.

In fact, more recently, weight gain has been added as a possible side effect as you can see for yourself in section 6.3 of this Advair insert.

Although it's mentioned under the following note: "Because (this side effect is) reported voluntarily from a population of unknown size, estimates of frequency cannot be made."

So it's obvious there have been more than a few with the complaint of weight gain while using Advair. At least enough to make weight gain worth noting under possible side effects.

Systemic corticosteroids, the kind given by IV or by mouth, can cause systemic side effects, including weight gain. When I'm on them -- and thankfully I haven't needed them in over 10 years -- I get an insatiable appetite (yep, I'd eat my fries and then finish yours too). Weight gain was inevitable.

Yet, despite old fears, studies have shown inhaled corticosteroids, including Advair, are safe, and side effects rare, so long as you rinse your mouth out. And this is still true for the most part, and for most patients.

I know I have seen some websites note that the higher dose (500/50) of Advair has been linked to increased side effects, as compared with the lower doses (100/50 and 250/50).

So, this makes me wonder if I might have been correct, and perhaps all those folks complaining of Advair weight gain were either on the higher dose, or not rinsing their mouths out properly.

Still, for some reason that doesn't seem plausible.

Another consideration that might cause weight gain for some who take Advair, and this is listed as a possible side effect, is possible fluid retention -- which may lead to weight gain.

Of course fluid retention is also a complication of illnesses such as heart and kidney failure, so if you have this then you ought to be calling your doctor to rule out other illnesses.

Only after other causes (including lack of activity) are ruled out can we start thinking that weight gain might be caused by a medicine such as Advair.

My coworker attended a class to prepare her for becoming an asthma educator a few years ago, and she learned studies showed being on a small amount of corticosteroid all the time (such as is provided by the daily use of Advair), is much safer than short bursts of corticosteroids.

So again, one must weigh the advantages of taking any medicine with the disadvantages. In the case of Advair, and for most patients, the benefits far outweigh the disadvantages.

As far as my experience with weight gain and Advair, in the past (back in 2002) when I did the Body For Life diet I lost up to 40 pounds in one 12 week period. Yet recently (after gaining my weight back because I'm normal) I only lost 20 pounds in 20 weeks. Now this could be age catching up to me, or the fact I didn't stick to the diet as well as I did in the past.

Yet -- and this idea crossed my mind -- it could be that I am now on Advair.

One of the advantages of Advair is you only have to take it twice a day, which I usually do just prior to brushing my teeth in the morning and at night.

In this way I don't miss doses like I used to. These results not only in better asthma control, but it also might increase my risk for side effects.

So, when I lost weight in 2002 I was not on Advair, I was using a Flovent inhaler and I often missed doses. Likewise, I did not use a spacer back then (a goofus perhaps?), which may have reduced the amount of corticosteroid in my system even further.

In essence, Advair improved my compliance and my technique, which results in better medicine distribution to my lungs. Could this possibly have also resulted in more side effects -- like weight gain?

Of course I am only speculating. Yet I know I'm not alone in thinking this way, as you can see by the discussions linked to above.

Some of us, however, may simply be trying to blame Advair for weight gain, when we should be blaming ourselves. A good diet and exercise can help one maintain a good weight. I'm not blaming the Advair, I'm just curious.

Still it would be neat to see further studies in this area.

That said I would never quit taking Advair. Never in my life had I had better asthma control than since I started this great medicine.

While side effects vary from person to person, and despite the warnings, they are still rare and minimal when they do occur. I highly recommend you discuss with your doctor trying Advair if other medicines don't give you the results you yearn for.

So what do you think? What is your experience with Advair and weight gain? Are there studies I'm not aware of? Discuss..

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How to draw people to your blog

One of the things every blogger years is to draw in a crowd of readers to his or her blog. Actually, if your goal is to make money off your blog, you don't even care how long they stay, because every click is a penny. Yet for most of us, the goal is to have people read your content.

My blog isn't the most well read blog on the web, yet I have managed to draw in an average of 500 clicks per day. In fact, just yesterday I managed to draw in 800 total clicks on pages of my blogs. Mind you each time someone looks at a different page on a blog it's considered a click, so 800 clicks might be 100 people, or even less.

There was one blogger who wrote a post, "How to attract people to your blog," and he said he made $1,000 per day by ads on his blog. So, by that, he managed to obtain 40,000 plus click on his blog every single day. If I obtained that goal I'd be in Heaven. Yet his blog had a popular topic: "How to improve your blog." Mine is less popular, as my audience is mainly chronically ill patients and respiratory therapists.

While his blog was about blogs, he said it's important you specialize your content to a particular audience, and in his case it was those who wanted to improve their blogs. In my case, it's respiratory therapy.

Yet he also wrote that you need to be honest. You can't just write to tell people what they want to hear, or what they can read on another blog. You have to be true to yourself, honest, and unique. And, on that same note, so long as you have good content, people will go to your blog even if they don't necessarily agree with your viewpoint on a subject.

To prove his point, he said that he believes in global warming and that the government needs to do whatever it can to save the planet, even if that means higher taxes and regulations. And I'm going to say I disagree with that. Yet, as I wrote before, if you want to learn about respiratory therapy, or if you want to learn what another RT thinks about this field, you'll read my blog. If you want to learn about asthma you'll go to Asthma Mom's blog, even though she quite often places her political opinions on her blog.

Yet I think it was asthma mom who wrote a post once about how one of her readers was upset by her viewpoint, and she responded by saying, "It's my blog. Of course my opinion is going to come across at some point." I paraphrased her there, but that's basically what I think she was saying. This is a blog. If people get that upset by hearing an opposing view then they shouldn't be reading random blogs anyway. If you have a particular interest, and you're an open minded person, then you'll want to hear the random thoughts of many people.

Yet most of your clicks don't come from regular readers anyway. Most clicks come from people doing Google searches and just so happen to land on your blog. Some will become regular readers, yet most will not.

So, that in mind, how do you attract people to your blog?

1. You have to write good content.
2. Make your blog entries pithy (short and sweet)
3. Be an expert
4. Be timeless. Write posts that will be readable for years to come
5. Share your experiences so others can learn from you and depend on you
6. Have a special topic for each day of the week so people know when you will be covering that topic and will search for your blog. I usually write about asthma Mondays, answer asthma questions Tuesdays, write RT Wisdom on Wednesdays, COPD and other disease wisdom on Thursdays, and answer your RT queries on Fridays, Saturdays are open, and Sundays are for any topic of my choosing.
7. Don't be afraid to write about off topics, such as I recently wrote a post my advice for Major League Baseball.
8. You should base your blog on a specialty, as mine is based on respiratory therapy
9. Write an occasional how to post. My two post well read posts are "EKG interpretation made easy," and "ABG interpretation made easy."
10. Write about new and unique viewpoints. Another one of my most viewed posts are the ones I wrote regarding my belief that the hypoxic drive theory is a hoax.
11. Be true to yourself in your posts. For example, you won't see my writing a post about how you should not give a patient the oxygen he needs because of the hypoxic drive theory. People can read about rehashed theories in any book or can hear it from any doctor.
12. Creat lists. For one thing, they are pithy and easy to read.
13. Enter your blog in google alerts
14. Write about the latest wisdom. These posts will be picked up by google searches and be sent to people in Google Alerts.
15. Announce news, but don't make your blog a bulleton board of news. I think it's best to announce news with your humble opinion and perhaps some other related facts.
16. Don't make a habit of writing about personal things unless they are relevant to your blog and rare. For example, my asthma blog where I tend to write more about myself is much less read than my RT Cave blog where I stick to the tips on this list. Don't write about your kids, your horses, or the blister on your toe.
17. That said, occasionally you should write about personal things as it helps to define you as a person. Just don't over do it (see #16 above)
18. Create an about page so new people can see who you are and what you're about
19. Make it easy to bookmark and share your blog entries on Twitter, Facebook, etc.
20. Create a unique header to spotlight your blog, but don't make it too big or too fancy as this tents to cause people to get lost in it.
21. Create a search icon so people can easily find things on your blog
22. Or create a table of contents where you list most relevent posts on a certain topic. I do this under the tags at the top of my page.
23. Make it easy for people to contact you. You can click my contact button.
24. Answer your email in a timely manner
25. Encourage your readers to subscribe to your RSS feed
26. Have relevant ads, and don't have too many ads
27. Make it easy to leave comments. If people can't leave comments they will probably just ignore your blog
28. Make your blog sticky. For example, create links to other posts you've written, like related links like this. This way people can become lost in your blog, especially if your content is useful and interesting.
29. Read other people's blogs and occasionally write a post about something another blogger wrote that is interesting
30. Create links to other bloggers
31. Leave relevant comments on other blogger's blog posts
32. Update your blog from time to time
33. Make sure your old links are still available. Otherwise, people will think your blog is old and lose interest
34. Update old articles you wrote when new wisdom becomes available and make your readers aware you did this. For example, my ABG interpretation made easy has been updated.
35. Edit what you write. Occasional grammar errors are fine, but too many and you'll start to lose readers.
36. Make your paragraphs short and pithy. I usually leave mine 1-3 sentences. Each sentence should have an independent thought. If you read newspapers, you'll see that sentences are short. This makes reading easy.
37. In your posts, make your point in the first few lines.
38. Make your headlines match what one might do a Google search for. For example, ABG interpretation made easy or EKGs interpretation made easy and my post about the hypoxic drive hoax will come up whenever someone searches for those topics.
39. Don't expect instant rewards. It will take a while to create an audience, maybe even years. Although if you stick to it, you should be rewarded with a good # of readers.
40. Yet don't be greedy. Don't expect to be one of those rare Bloggers who draw in 40,0000 a day. I'm happy with 400. Heck, I'm happy with zero.
41. Write every day, or nearly every day.
    Don't go on a long blogging hiatus
42. When you make a mistake, own up to it and apologize in a timely manner and sincerely.
43. If you got an idea from another person, give credit and link to that person like I'm doing here. I got some ideas for this blog post from this blogger.
44. Provide facts and link to your sources. This will give you credibility.
45. Give away things for free (I've been told this is the best way to create an audience, yet I can't think of relevant things to give away on an RT blog).
46. Don't blog more than once a day
47. Write relevant guest posts for other bloggers or online magazines. I did this here and here.
48. Read how to get people to your blog posts like this. In fact, it was from this blogger I borrowed the pie chart.
49. Realize that most people don't care about you, they want content based on facts

Study might prove modern asthma theories

I wrote about the hygiene hypothesis here at MyAsthmaCentral a few years ago. This is a theory that postulates that our very own cleanliness might make us more susceptible to developing asthma. Another new study has scientists thinking about this hypothesis again.

The recent study by researchers at Tuft University compared the results of previous studies on th subject and, as reported on here at ScienceDaily.com, Americans born of low socioeconomic status in the United States and exposed to such things as cockroaches and mice were more likely to develop asthma than people of similar socioeconomic status in other countries (such as China).
The hygiene hypothesis states that if the immune system is not stimulated by certain pathogens (bacteria, viruses, intestinal worms, etc.) within the first three months of life, the immune system becomes bored and starts to create a defense against otherwise harmless substances such as your own body, dust mites, cockroach urine, molds, pollen, ragweed, etc.

In essence, if your immune system gets bored, certain autoimmune diseases such as asthma, eczema, and arthritis may be the result.

This new study might confirm that pathogens in the air that might help the immune system to mature are probably present in other countries while not present to the same extent in the United States.

The study might also confirm that people from other countries are exposed to more sunlight, which might prove the theory that lack of vitamin D may also be a cause of asthma. Some studies have also confirmed a link between lower levels of vitamin D and asthma.

The study notes the following significant (at least I think they are significant) statistics:

1. They found that U.S.-born children who were exposed to pests were 60 percent more likely to have asthma than U.S.-born children not exposed to pests. Pest exposure had no statistically significant impact on asthma risk in foreign-born children.

2. U.S.-born children with low socioeconomic status were two times more likely to have asthma than U.S.-born children without low socioeconomic status, while low socioeconomic status had no statistically significant effect on asthma risk in foreign-born children.

So while scientists don't yet know exactly what causes one to develop asthma, we have some viable theories. However, it is possible that more than one thing causes asthma, and for this reason we must not get too excited about any one particular theory -- this will keep us open minded.

Respiratory Health- what you should know!

The following is a guest post by Keith hoffiel, a writer for onlineschools.org

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The most widely known and important part of the respiratory system is the lungs, a pair of organs that are located within the chest. The respiratory system also involves the trachea, windpipe, and those parts involved with blood circulation.

Without our lungs we wouldn’t be able to breathe, and without breathing we wouldn’t be able to live. The primary function of the lungs is to allow oxygen to enter our bodies. They are also needed for the release of carbon dioxide. Without oxygen our internal organs would not be able to function. Too much carbon dioxide in the body causes all sorts of health issues.

Factors That Affect Your Respiratory Health

There are several factors that have a large affect on your respiratory health. These factors can negatively and positively affect how healthy or unhealthy you are when considering your lungs.

Weight

You may know of the various benefits of living with a healthy weight and BMI, but not many people are aware that your weight can affect your overall respiratory health. Those who are overweight are more prone to developing respiratory health conditions such as asthma, bronchitis, and others. This means if you’ve already been diagnosed with asthma, losing weight may lessen the symptoms. If you don’t have asthma but are overweight, making the scale move downwards will greatly decrease your chance of being diagnosed with the health condition.

The less weight your body has to carry around, the less strenuously your body, especially your lungs, need to work. Think of it this way: someone who is fit and at an average weight can usually run for much longer without feeling light-headed and out of breath when compared to someone who is overweight.

Stress

Stress plays a large role on our health. When looking at the respiratory system, bad stress is known to cause an increase in breathing which means an increased heart rate, higher blood pressure, and other effects. If your life is full of a lot of bad stress, your respiratory health may be negatively affected. Stress is known to cause asthma attacks and overall decreases the strength of your immune system. This makes you more susceptible to illnesses of all kind.

These and other factors will determine how healthy your respiratory system is.

Keeping Up With Your Respiratory Health

If you’re looking to increase the health of your respiratory system, there are various things you can do. Doing something as easy as taking a vitamin each day can greatly increase how healthy your lungs are. The overall health of your body and other internal systems will have an effect on your lungs.

For example, having a healthy heart can greatly increase your respiratory health. Exercising or eating right to improve your cardiovascular health is just one way to improve your respiratory health. Since the respiratory and cardiovascular systems are heavily reliant and connected, it is no surprise the health of each go hand in hand.

A very common way to improve respiratory health is to kick habits such as smoking. Smoking has proven to be detrimental to the lungs and other connected organs. Ridding of this type of habit is sure to improve your respiratory health.

For some, respiratory therapy is an ideal way for proper care of the lungs. This type of therapy is best for those who suffer from chronic respiratory infections or respiratory illnesses such as COPD and asthma.

If you’re looking to become an expert with respiratory health or if you’re looking to learn more information about your lungs, it may be a good idea to find an online respiratory therapy school
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Remember that taking care of your lungs is a full-time job. This means quitting any harmful habits and taking the proper medicines and vitamins to treat the flu, the common cold, or a respiratory infection.

It’s important to take care of your lungs when you are sick and when you aren’t it’s even more critical to keep them working properly and free of any type of infection.

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Keith hoffield is a avid writer and a loves to learn. When he is not writing for onlineschools.org he enjoys diving into a good book.

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The argument against ABGs

The argument for venous blood gases instead of arterial blood gases

Something we've been discussing at Shoreline Medical recently is the possibility of doing fewer
arterial blood gases (ABG) and more venous blood gases.

Sure an ABG is necessary when monitoring a patient in respiratory distress, although for the most part, there really isn't any more information you can obtain in an ABG that you can't simply obtain from a venous blood gas, coupled with end tital CO2 monitoring (ETCO2) and oxygen saturation (SpO2) monitoring.

Consider you have a patient with diabetes. The doctor wants to determine pH. If a pH is all the doctor wants, then a venous blood gas will work just great, as venous and arterial pHs are basically the same.

A 1998 study (as noted in this article from Emergency Medicine) found that in patients with diabetic keto acidosis, the venous pH was remarkably similar to the arterial pH.

Our Sepsis protocol calls for any patient suspected of having Sepsis to have an ABG. The reason is to get a baseline pH. Since this is the only reason, a venous blood gas would suffice.

The same with overdose patients. Poison control wants an ABG to be drawn when certain medicines are overdosed on. The reason is to check for pH. This is another example when a venous poke would suffice.

Think about it though. A venous poke is much less invasive and risky as an arterial poke, and the lab is in the room of the patient anyway drawing all the other labs. So, then it would be much better on the patient just to have all labs, including ABG, on just one poke.

In fact, according to Emergency Medicine, "When Is Venous Blood Gas Analysis Enough?" (38(12):44-48, 2006), revealed that a study performed in 1996 determined that most patients said a venous poke was about half as painful as an arterial poke.

You have a patient on a ventilator. Currently our protocol calls for daily ABGs. Our medical director is presently trying to convince the medical staff where I work that serial ABGs are not needed. What is needed is a continuous pulse oximeter and an end tidal CO2 monitor.

Then, 30 minutes to an hour after intubation, an ABG should be drawn just to get your baseline pH and to make sure the ETCO2 monitor and SpO2 correlate with the actual PO2 and CO2. That's it. From then forth all you need is daily venous pH. To monitor PO2, all you have to do is monitor the SpO2 and ETCO2.

A normal SpO2 is 90 or better. According to the oxyhemoglobin association curve, the PO2 is 30 less than the SPO2, therefore an SPO2 of 90% is equivelent to an SpO2 of 60, and an SpO2 of 80 correlates to a PO2 of 50. So there you have it.

Thus, according to the oxyhemoglobin disassociation curve, the formula goes like this (SPO2 minus 30 = PO2):

SPO2 of 90 = a PO2 of 60
SPO2 of 80 = a PO2 of 50
SPO2 of 70 = a PO2 of 40

It's basically called the 4-5-6-7-8-9 rule.

As far as monitoring CO2, all you have to do is monitor ETCO2. As the ETCO2 rises and falls, so to does the PCO2. A normal ETCO2 would be 30 to 50. Unless the patient is a CO2 retainer, all ETCO2 results greater or less than that should be reported to the physician.

Basically, if you have a patient who is not in respiratory distress, an ABG is never needed.

The proof

The toughest argument I've had is convincing doctors that a venous pH is basically the same as arterial pH. I remember once being called to do a stat ABG on a patient, and the pH on the patient was 6.78 and the CO2 was 75. The doctor was convinced I got venous blood and wanted me to redraw.

I took the gas to a second doctor, and he too was convinced I had obtained venous blood. I knew I had arterial not just by how forcefully the blood entered the syringe, but because the bicarb was 33 which shows the patient was probably a CO2 retainer to start with. Yet the doctors made me redraw the ABG. Of course it came out exactly the same, and they once again were convinced I had venous blood.

So the debate is ongoing. Yet, as you can tell by the picture, venous and arterial pH are essentially the same in a healthy patient. Why doctors are so convinced there is a major difference between the two is beyond me. Likewise, the bicarb (HCO3) is essentially the same too.

The only major difference is PO2, which can be monitored by saturations, which is completely non-invasive. There is no reason to ever draw an ABG just to prove that the PO2 is low. Again, all you have to do is subtract 30 from the SpO2 and you have your PO2.

The Emergency Medicine article notes a study done way back in 1985 that basically proved that "a venous pH of 7.25 or higher predicted an arterial pH of 7.2 or higher in 98% of all cases, which makes VBG testing valuable as a screening procedure.If the results are normal, ABG analysis should not be necessary. Conversely, abnormal venous levels predicted abnormal arterial values, but again in a nonlinear fashion. A venous pH of 7 or lower, for example, predicted an arterial pH of 7.2 or lower in 98% of cases. "

Here's another catcher the Emergency Medicine article notes. I have tried to convince doctors for years that an ABG is not needed during a code because if a patient is not breathing you already know the pH is low. Likewise, regardless of what the ABG shows, it's not going to alter what you do to try to save the life of the patient. So there is no need to rush to do an ABG.

In other words, you do not need to do an ABG to diagnose hypoxemic respiratory failure when the patient is showing obvious signs of hypoxemic respiratory failure.  Attempts to draw blood only delay treatment, and this can only increase morbidity and mortality.

The article is the first I've found that attempts to prove my point. It notes the following:

In cardiac arrest victims, the disparity between arterial and venous values is even greater. During cardiac arrest, tissue hypoxia is all but a certainty and is reflected by the lower pH and higher PCO₂ on the venous side. A 1986 study by Weil demonstrated a significantly lower pH in venous samples (mean, 7.15 vs 7.41 in arterial samples) and a significantly elevated PCO₂ (mean, 74 mm Hg vs 32 mm Hg) in these patients. In clinical practice, however, knowledge of either the arterial or venous pH or PCO₂ during cardiac arrest does not alter management, making the debate less relevant.

What's most interesting is my point was proven way back in 1986. Why is this information not translated in medical school? Yet, regardless, the argument is simple, that ABGs are needed sometimes to help a physician manage the care of a patient, yet more often than not a VBG will suffice.

Slow growth in utero may cause asthma

So you have asthma. Perhaps the cause is that you were a slow growing fetus when you were inside your mommy. A new study shows this might be the case, as you can read here.

These test results are actually quite significant, and show that those who grew quickly early on in pregnancy and then grew slow during the later stages when the lungs were developing were 27% more likely to develop asthma.

To me, 27% is a significant number. Still, this is scant compared to the evidence that 80% of those born by c-section are likely to develop asthma, as I wrote about here.

The theory here is that lungs that develop more slowly may be narrower and more prone to be susceptible to irritants that might result in airway hypersensitivity and therefore narrowed airways (or asthma).

Therefore, these infants are more likely to have wheezes, be more susceptible to common colds, and this may be as a result of the narrowed air passages (bronchioles).

While there may be an amalgamate of reasons why people develop asthma, this is more evidence of why it is sooooooooooo important for moms to take good care of themselves when they are pregnant. They should not smoke, they should not take medicine without talking with their doctors, they should limit caffeine, they should not hang around people who smoke, etc.

Moms: Beware! What you do during pregnancy can cause serious health consequences for your child that he or she will have to deal with his or her entire life. Heed this warning!!!!

Here's the new definition of asthma

As you can see from last Monday's post, the definition of asthma is constantly changing. This is a good thing, because it means we're getting smarter. It means we're getting closer to getting this disease under control, and it may some day mean a cure.

This was the topic of a recent post from MyAsthmaCentral.com

So What is Asthma? Here's Our Updated Definition

Even during my short lifespan the definition of asthma has changed quite a bit. It's important we asthmatics keep up on the current definition, because how asthma is treated is dependent on how it's defined.

In 1985 I was taught the acronym ROAD to easily define asthma, which stands for Reversible Obstructive Airway Disease. ROAD's still valid, yet no longer complete.

Today we know asthma is still ROAD, yet it's also a disease where the air passages in your lungs (called bronchioles) are chronically (always) inflamed or swollen, and thus are very sensitive to various stimuli called asthma triggers.

When exposed to asthma triggers, this inflammation becomes worse and the muscles (bronchial muscles) surrounding the bronchioles spasm (called bronchospasm) and this narrows the bronchioles, thus trapping air in your lungs.

This process is called an acute (happening right now) asthma attack, also called an asthma flare, or an asthma exacerbation. (View normal & asthmatic lung here).

Another thing that may occur during an attack, which narrows the bronchioles even further, and thus exacerbates this problem, is that cells lining your air passages secrete excess secretions. If this process becomes severe, this mucus may become thick and actually block the air passages. This is called a mucus plug.

As this process worsens, this air trapping may cause a progressive hyperinflation of the lungs, making the asthmatic appear to have hunched shoulders and an increase diameter of the chest (see picture). Another reason for hunched shoulders is the patient's attempt to make more room for air exchange.

All these processes ultimately increase the patient's work of breathing. It may feel as though you can't get air in, but you are really having trouble getting trapped air out.

These patients may actually lean on things to breath, and children often present in the emergency room with their fingers clenched into the side of the bed, shoulders high, in what we like to call the frog position.

Between asthma episodes, however, most asthmatics have no symptoms, and can live normal, active lives. This, ultimately, is the goal of asthma therapy: to minimize symptoms.

The key component of asthma is that this entire process is completely reversible. Sometimes symptoms are mild and they resolve on their own. Other times medicines are needed and occasionally more invasive therapies.

There are three types of asthma:

1. Intrinsic: This is where the stimuli that trigger your asthma are anything but allergies. Most of the people with this type of asthma have adult onset asthma. Some examples are chemicals inhaled via cigarette smoke, chemicals inhaled at work or home (such as from household cleaners), strong smells, humidity, aspirin, emotions, stress, chest infections, GERD, and exercise induced bronchospasm.

2. Extrinsic: This is where the stimuli that trigger asthma come from allergens. Some examples include dust mites, cockroach urine, mold, fungus, pollen, grass, trees and animal dander. Since 70 percent of asthmatics also have allergies, this type of asthma is often called allergic asthma or atopic asthma. Most asthmatics diagnosed with childhood onset asthma have this type.

3. Mixed: Many asthmatics, me included, have a combination of intrinsic and extrinsic.

Back when ROAD was taught, the goal of asthma therapy was to treat acute symptoms (as I wrote about here). With our new asthma wisdom the goal is to prevent asthma, yet to have a plan to treat acute symptoms when they do occur.

So, current treatment for asthma focuses on the two main components of asthma: Acute bronchospasm and Chronic Inflammation. Yet there are actually four possible components of asthma:

1. Acute Bronchospasm: Beta adrenergic inhalers and aerosol solutions (also called bronchodilators or rescue medicine) like Albuterol and Xopenex cause bronchiole muscles to relax, and dilate the bronchioles (bronchodilation) which makes breathing easier.

It's recommended that every asthmatic at least have a rescue inhaler on his or her possession at all times. Asthma is usually considered controlled if you have fewer than two to three acute asthma episodes in a two week period, however there are exceptions.

Some asthmatics only need to carry a rescue inhaler to treat their symptoms which occur rarely. However, a majority require controller medicines to prevent asthma attacks.

2. Chronic Inflammation: The best medicines to treat this are inhaled corticosteroids such as Qvar, Pulmicort, Flovent and Azmanex.

If these alone do not control asthma, a leukotreine blocker (like Singulair and Accolate) may be prescribed to control inflammation and block the allergy response. For some, Singulair alone controls asthma.

3. Combination: Many asthmatics use combination inhalers such as Advair and Symbicort, which have both an inhaled corticosteroid to control inflammation and a long acting beta adrenergic to prevent bronchospasm. Actually, this is currently the most common approach to treating asthma.

4. Airway remodeling: Asthma experts recommend asthma be swiftly diagnosed and treated. When asthma is not treated over a long period of time permanent airway changes can result, and this often leads to severe asthma or COPD. This type involves less than 10 percent of asthma cases, and treatment is generally more complicated.

(For more detailed information about asthma medicines click here.)

So our current definition is a disease of chronic inflammation that worsens and causes bronchospasm, airway obstruction, and air trapping when you're exposed to your asthma triggers. Acute bronchospasm can be reversed, and inflammation can be treated with asthma controller meds.

Ultimately, with good asthma control, most asthmatics should be able to live normal, active lives.

Can you think of a new acronym to describe asthma?

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Our experience with Gift of Life

My wife and I had our own experience with gift of life recently. After her mother passed away unexpectedly from a brain aneurism, my wife and her three siblings decided her mother would want to do this.

They decided that even though her mother stated she would not want to donate her organs. She came to that conclusion because when she was a student she watched the gift of life take organs from a patient, and for some unknown reason the organs ended up being wasted. So that gave my wife's mother a sour taste about the idea of donating.

However, when the occasion came up, my wife said, "You know, an irony about this is that while this is our time of grieving, seven or eight people could be celebrating right now."

So the "reasonable" decision was made to trump their mother's decision. I remember watching over this discussion. Here four siblings in their 20s were standing around the lifeless body of their mother who was still on a ventilator making decisions people in their 20s normally don't have to make these days.

Back in the 18th century every family had death experiences. It was common for people in their 20s to have their parents die. It was common for infants to be born dead. In fact, at the time of Jesus 50% of children didn't make it to adulthood. Yet, thanks to modern wisdom and medicine, we just don't see death as often anymore.

So here my wife and her siblings were facing death for the first time. And a few days later the nurse came to my wife and said, "You know, I've seen many people die in the past year, and you are only one of four who decided to do the gift of life without consulting the gift of life first. I'm very impressed."

I recently talked to the gift of life representative here at Shoreline, and he said the law has it that a nurse or doctor is not allowed to approach a family about gift of life. However, if a person is close to dying, or even if the doctor thinks a person might die, the gift of life has to be called. Then it's up to the gift of life representative to approach the family. They are trained to do it.

Plus I imagine there might be a conflict of interest for the nurses and doctors trying to save a life to be coaching on Gift of Life.

So he said there are many people who decide to give to the gift of life, only a few do it without first being consulted. However, my wife is a nurse. She's also quite smart and reasonable.

My dad had a similar experience when his brother passed away after he hit his head as a result of a car accident. He was on his way to our house, and he lived only a mile away. All he had to do was cross the highway. He was teaching his 15 year old daughter to drive a stick shift. It was Memorial weekend. He was taking apples to our house to feed the deer.

The Jeep stalled at the intersection. Uncle Ted, who always wore a seatbelt, just unhooked the seatbelt because he was going to switch seats with his daughter. Yet just then the jeep was hit on the driver's side by an 88 year old driver.

The other driver wasn't going fast, and the hit wasn't hard, but just enough to knock uncle Ted out of the side of the Jeep where he hit his head on the curb. Dad was a member of the fire department, and ironically he was the first on the scene. He said Tad was talking to him, or screaming, "It hurts, Bob. Help me!"

This was back in 1989. This was back when the emergency helecopters were new. The Big Hospital up north just got one. My uncle was going to be the first passenger. He needed to have his head tapped to relieve pressure, but he had to be transported to the Big Hospital -- and fast.

Well, dad said the bed he was on didn't fit in the helecopter, so they had to wheel Ted back into the emergency room. It wasn't for another hour before they got him in the helecopter. By the time Ted arrived at the Big City Hospital it was too late to tap. Two days later he was pronounced brain dead.

Tad's wife asked dad what to do about organ donation. Dad said to her that Ted loved people and he would love to do this. Tae would be very happy with that decision. Yet his wife was scared and said, "But I can't do that."

So my uncle took his organs with him. That's fine. Yet back then the wisdom wasn't what it is today. Today we know that organ donation works. It saves lives. Grandkids and kids will be able to spend some more years with the 57 year old grandma who received the lungs of my mother in law (she was only 50).

Before this experience I personally was leary about donating my organs. However, when I was filling out the paperwork to get my new Michigan drivers license, and the lady asked me if I'd like to be a donor, I found myself saying, "yes!"

Now I know that little red "donor" next to a red heart over my picture (a much better picture than my last one I must add) has no legal significance, yet it might help someone make the decision later down the road. If something happens to me, I certainly don't want my organs to be buried with me. I won't need them in Heaven.

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A better vocabulary improves communication

I've always enjoyed learning new vocabulary words. Every day I try to find a new word by some means, either from a dictionary, something I've read or by conversation. I think it's neat to study words and learn their origin and meaning. I usually find that by learning one word I improve my use of the words I already know.

Actually, I use some of the words I learn in my daily life, but not all. And the goal isn't to complicate the way I communicate, yet just the opposite. The point by using better vocabulary is to make communication easier. The point is to use pithy sentences.

That is how an improved vocabulary is described in this post over at Litemind.com. The article notes that, "the point of having a good vocabulary is being able to choose words with greater precision."

A vocabulary adds to your toolbox of wisdom. The article notes:

" Think of your vocabulary as your “communication toolbox”: every word is a tool, ready to be used at the right time. The more tools you master, the better your chances are of finding the right one for the communication task at hand.

Just pick a word and roll it around in your head for a day. If it sticks, you'll be all the smarter. Likewise, it will make you a better RT by improving your communication skills.

New study shows outdoor wood stoves unhealthy

When I was a kid my parents decided to take the cheapest route home heating and had a wood furnace installed in our basement. This decision might have been good for their pocket books, yet it wreaked havoc on my lungs and therefore my life.

Not only do wood stoves give off smoke that can irritate lungs, but all the wood stacked in the basement was filled with molds and fungus that are known allergens for me and many other chronic lungers. The smoke outside meant I couldn't play out there, and the mold and fungus inside made indoor life equally miserable.

My parents ultimately were told this was bad for me, and there response was to shut off the wood heating ducts to my room and turn on the gas just to heat my room. Yet little did they realize that while this effort was a good gesture, it was frivolous at best.

A new study reported by the Environment and Human Health Inc. as reported here reveals the following about outdoor wood furnaces (OWF):

"Wood smoke contains many of the same toxic compounds that are found in cigarette smoke. Just a few of them include benzene, formaldehyde, and 1,3-butadiene, all three of which are carcinogenic."

In fact, while indoor wood furnaces are a bad enough asthma trigger, "The Northeast States for Coordinated Air Use Management (NESCAUM) found that the average fine particle emissions from one OWF are equivalent to the emissions from 22 EPA-certified indoor wood stoves, 205 oil furnaces or as many as 8,000 natural gas furnaces."

The study also reported the following (PM stands for particulate matter, which is the particle size of the smoke measured):

• A house 100 feet from an OWF had 14 times the levels of PM 2.5 as houses not near an outdoor wood furnace and 9 times the levels of the EPA air standards
• A house 120 feet from an OWF had over 8 times the levels of PM 2.5 as the houses not near an outdoor wood furnace, and 6 times the levels of the EPA air standards.
• A house 240 feet from OWF had 12 times the levels of PM 2.5 as the houses not near an outdoor wood furnace and 8 times the levels of the EPA air standards
• A house as far away as 850 feet from OWF had 6 times the levels of PM 2.5 as the houses not near an outdoor wood furnace and 4 times the levels of the EPA air standards.
• High levels were present in every 24-hour period tested inside homes neighboring outdoor wood furnaces
• All houses tested had particulate exposures well above the EPA ambient air quality standard.
• Levels of PM 2.5 that exceed the EPA standards are associated with asthma or chronic obstructive pulmonary disease (COPD) attacks and hospitalizations, and are also associated with increased risk of cardiac attacks.
• Particles of wood smoke are so small that windows and doors cannot keep smoke out
• A study by the University of Washington, Seattle, showed that 50 to 70 percent of outdoor wood smoke entered homes that were not burning wood.
• Because wood smoke particles are so small, they are not filtered out by the nose or the upper respiratory system. Instead, these small particles end up deep in the lungs where they can cause structural damage and chemical changes.
• Carcinogenic chemicals and wood smoke irritants adhere to the small particles and enter the deep, sensitive regions of the lungs where toxic injury is high.

The short term, or "irritable" side effects of inhaling smoke from outdoor wood heaters include:

• Night time coughing
• Headaches
• Inability to catch breath (dyspnea)
• Burning throat
• Burning eyes
• Bronchitis
• Pneumonia
• Colds
• Increased respiratory infections (particularly in children)
• Missed days of work or school
• Emergency room visits

The long term side effects of inhaling from outdoor wood heaters include:

• Increased risk for lung cancer
• Asthma
• COPD
• Cardiovascular problems
• Carbon monoxide poisoning

In fact experts note that "Even episodes of short-term exposures to extreme levels of fine particulates from wood smoke and other sources, for periods as short as two hours, can produce significant adverse health effects."

The particulates breathed in are not only linked with chronic lung disease but to lung cancer, as evidence shows the smoke inhaled also contains known carcinogens. So short-term exposure may result in either asthma, COPD, and long term exposure to those plus lung cancer.

So smoke from indoor and outdoor wood furnaces have the same known harmful chemicals as cigarette smoke, smoke from outdoor wood stoves is thicker and more prevalent in the air, and is more "pervasive for those who live near them," said Dawn Mays-Hardy of the American Lung Association, New England.

Likewise, "Resident of Environment and Human Health, Inc. Nancy Alderman says, "EHHI has now shown that wood smoke from outdoor wood furnaces enters neighboring houses in high enough amounts to cause serious health impacts to these families. States can no longer ignore this science and should ban outdoor wood furnaces until safer technologies are found."

COPD more common than thought

When I started RT school 15 years ago I saw a pulmonologist who had a chart on the wall that showed how most Americans will get COPD at some point in their lives. It showed a chart that graphed how as we aged, COPD prevalence increased.

So we are all susceptible to getting COPD. What speeds up this process, and therefore the process of aging, are certain chemicals, many of which are prevalent in cigarette smoke. And this is why cigarette smoke is the main cause (like 80% of cases) in COPD in people under 80 years of age.

Likewise, of all cases of COPD, 80% are current or former cigarette smokers. Likewise, of all people who smoke, 20% will be diagnosed with COPD.

As Jeffrey Hersh of Gateway News Service writes here, COPD is thought to be prevalent in 10% of Americans over the age of 40, and is the 4th leading cause of death in the United States. Yet, he writes, "Evidence of COPD is found in two-thirds of men and over a quarter of women (this is increasing) at autopsy, so it is more common than this 10 percent figure suggests."

And despite current statistics, more than just the 20% of smokers and 10% of Americans will have to make lifestyle changes due to the effects of COPD. At least this is according to autopsy reports.

However, as I noted in my opening paragraph, this is not new news. Even in old asthma books I've read dating back to the early 1800ss, doctors and asthma (which back then included all lung disorders, including COPD and heart failure) found that emphysema was prevalent in most asthma patient autopsies.

Other than smoking, here are some risk factors for developing COPD:

• Cigarette smoking
• Other chemical or irritant exposure (occupational, wood smoke, pollution,etc.)
• Asthma (hyperresponsiveness or allergies)
  
• Alpha 1 antitrypsin deficiency
  
• Tuberculosis
• Bronchopulmonary dysplasia
• Bronchiectasis
• Lupis
• Cystic Fibrosis
• HIV (may make COPD worse)
• Obesity (may make COPD worse)
  
• Very skinny (may make COPD worse)
  
• Aging

There is no cure for COPD, so Dr. Hersh notes if you develop COPD, you should heed the following advice:

• If you smoke, stop
• Avoid exposure to chemical and other respiratory irritants
• Keep your weight at a healthy level

For more information about COPD, check out this link: COPD wisdom