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Friday, July 17, 2015

Understanding stupid doctor orders, or SEE I TOLD YOU SO

Going all the way back to the ancient world doctors have written orders based on the following question: "Does it sound like a good idea?"

Unfortunately, even in the modern era where science rules the day, most medical theories are still based on this question.

It was based on asking this question that all pulmonary diseases have been treated as asthma since the beginning of civilization.  This was how the gods were thought to cause, prevent and cure all diseases in the primitive world: it sounds good.  This was how the hypoxic drive theory was postulated and became the golden rule of COPD, even though it was based on one fallacious study.  Despite it being disproved over a hundred times over the years, physicians still believe it to be true "because it sounds good."

Yet modern thinkers have challenged many of the old medical dogma's that have plagued the medical profession, and we can begin right here in the respiratory therapy profession.  I myself, for example, with the support of many of my peers, challenged the medical profession long ago on this blog by stating that albuterol does not enhance sputum production.  

We came to this conclusion by asking a better question: "Does it make sense?" Does it makes sense that oxygen knocks out the drive to breathe in COPD patients?  No, it does not.  Why? Because we oxygenate COPD patients all the time and they never stop breathing.  So we came to the conclusion that if they stop breathing, it's because they were going to anyway.  It is a proven fact that people need oxygen or they will die.  If they stop breathing, we use provide positive pressure breaths to improve ventilation.  

Does albuterol cure pneumonia? Does it sound like a good idea? Yes.  Does it make sense? No, it does not. Albuterol particles are the perfect size to attach to Beta 2 receptors in airways, but too large to even make it to the terminal air passages and alveoli, where the pneumonia is present.  Plus their are no beta receptors in the terminal airways anyway, so the albuterol wouldn't do any good anyway. Plus, albuterol is a bronchidilator, and pneumonia is inflammation.  

So a doctor challenged me on this as a result of my article "A World of Bronchodilator Lies."  He said the fact that some studies show that albuterol does increase sputum production is evidence that I am wrong.  I stuck to my guns on the basis that his theory sounded good but made no sense.

But now I have been vindicated.  Now I get to say "See, I told you so."  The new AARC Clinical Practice Guidelines, as reported By RT Magazine, now state the following:
There is no high-level evidence related to the use of bronchodilators, mucolytics, mucokinetics, and novel therapy to promote airway clearance in the studied populations. 
So, does albuterol enhance sputum clearance?  Well, does it sound good? Yes, so doctors will order it. Does it make sense? No, so respiratory therapists will doubt it does any good.

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