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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.

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