Here's how NIV benefits CO2-retaining COPD patients

I often tell my patients that nothing I do cures any ailment.  To the contrary, I tell them that the procedures I perform treat acute symptoms, while the doctor and nurse do other things that will provide the cure.

A perfect example of this is with noninvasive ventilation (NIV) for treatment of acute respiratory distress due to chronic obstructive pulmonary disease (COPD). Savi et al, 2014, notes the following:

Noninvasive ventilation benefits patients with COPD, and it seems reasonable to expect that NIV would increase tidal volume and improve CO2 elimination, and thus reduce respiratory drive.

The note the studies have proven that NIV results in the following when used on COPD patient's presenting to the emergency room with flare-ups:

• Reduction of treatment failure
• Lower mortality
• Fewer complications
• Lower Intubation rates

However, the studies also conclude that:  "In these patients CO2 elimination is increased but overall ventilation-perfusion mismatch is not changed during NIV. 

What does improve ventilation, the authors note, are the following:

• Treating precipitating factors (eg, infection with antibiotics)
• Increase expiratory flow (eg, with beta agonists)
• Reduce pulmonary inflammation (eg, with corticosteroids)
• Manage gas exchange (eg, improve oxygenation)

Without NIV, studies have shown, patient's who have COPD with CO2 retainers should receive an FiO2 just enough to maintain an SpO2 of 88-92%, as higher FiO2s (either due to the loss of hypoxic drive, or V/Q mismatching) have been shown to cause a rise in PaCO2.  

However, this effect is negated with NIV.  Savi et al concludes:

During NIV with an FiO2 sufficient to maintain a normal PaO2, a further increase in FiO2 does not result in an increase in PaCO2 in CO2-rataining COPD patients, since no changes occur in (minute ventilation).

Crossley et al had similar results, concluding, that "CO2-retaining COPD patients following a period of mechanical ventilation with PaO2 in the normal range can safely receive supplemental oxygen without retaining CO2 or a depression of respiratory drive.  A new ventilation-perfusion relationship is established during ventilation to normoxia, and it is not altered by further increasing FiO2," Savi et all reports.

Since NIV helps COPD patients take deeper breaths, thus improving their ventilation (allowing them to blow off CO2), high levels of oxygen do not cause rising PaCO2 levels while a patient is receiving NIV therapy.  However, we often find that, while using NIV, many patients require less oxygen compared to prior to the NIV start.

Bottom line:  NIV is beneficial to CO2-retaining COPD patients because it increases their tidal volume, increases CO2 elimination, and reduces their drive to breathe.  By treating these symptoms, caregivers are provided an opportunity to do whatever is necessary to treat the cause of the exacerbation (even if that means utilizing higher oxygen levels).

References:

1. Savi, Augusto, Jucara Gasparetto Maccari, Tulio Frederico Tonietto, Ana Carolina Pecanha Antonio, Roselaine Pinheiro de Oliveira, Marcelo de Mello Rieder, Evelyn Cristina Zignani, Emerson Boschi da Silva, and Cassiano Teixeira, "Influence of FiO2 on PaCO2 During Noninvasive Ventilation in Patients With COPD," Respiratory Care, March, 2014, volume 59, number 3, pages 383-387

Can a cat cause a low SpO2?

The patient is admitted through triage, and her SpO2 is 78% on 3lpm.  The patient is wearing her home oxygen equipment.  As soon as the patient is admitted into an ER room, I disconnect the patient from her tank and hook her up to the wall.  As I did this I said, "Turn your oxygen off and save it for the ride home."  So I did this as a good gesture, not for any therapeutic reason.

Lo and behold, after I plug her nasal cannula into the wall flowmeter and turn it to 3lpm, her SpO2 slowly goes up and up and up until it's 98%.  This, my friends, is a tell tale sign that her tank was empty.  Upon further investigation, I learned that she had a cat, and the cat had clawed through the tubing on her oxygen machine at home.  She didn't think this would make a difference, but apparently it did. 

So, do you know how we figured out her cat was the cause of her low SpO2?  Well, we did a CAT Scan! 

Okay, so I'm kidding about the CAT Scan part, but the rest of the story is true.  The patient was discharged to home after a single albuterol breathing treatment and a bolus of solumedrol, although a part of me thinks all she needed was her oxygen back.  Home care was called, and they fixed that part. As far as the cat... well, your guess is as good as mine.

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My Interview with Roxlyn Cole, a COPD Patient

One of the reasons I decided to become an RT was because I have asthma, and I figured I'd have empathy for my patients. What I learned after starting this profession is that the patients we treat most often are not asthma patients, but those with pneumonia and exacerbation of COPD. However, I still have empathy for them.

I can tell you what it's like taking care of COPD patients because I have had many long discussions with many of them. Still, I thought it would be neat to get an up close and personal view from a person who has lived with COPD. That in mind, I contacted Roxlyn Cole.

If you have COPD perhaps you've heard of her by perhaps reading her blog or by the fact she's an active member of the COPD community. I got to know Roxlyn through her blog and mine, and recently I asked her if she would mind writing about what it's like to live with COPD. She agreed.

We decided the best way to do this was for me to email some questions. What follows is my Q&A with a Roxlyn:

When did you first realize you had COPD, and what was your initial reaction?

I was told over the telephone by my primary doctor about test results 6:30 pm...he was so apologetic, I was consoling him, not know at all what it was all about, or how permanent the oxygen use would be.

My reaction to the delivered E tank was: "I will never go out of the house, I'm not THAT old. I asked if they had a smaller cylinder, they did, and that one looked downright 'sexy' in comparison to the tall E cylinder of compressed gas O2.

Did you ever say, "Why me?"

Not really, I figured we all get something sometime, and as inconvenient as being on a leash - tube of oxygen is, it beats a lot of other problems, and I was lucky to be caught early...mild/borderline moderate..

Was your COPD caused by smoking?

Probably that was a factor, along with occupational and hobbies-dust-fumes-pollution.Dry wall dust makes great lung sediment...refinishing furniture is another thing I did, along with being pool/aquatic director manager...oh that chlorine.

If so, how much did you smoke and how many years?

I smoked one to two packs per WEEK from age 17, with several LONG quit periods of 2 to 4 years long, thus 40 years.

What was the hardest part of quitting?

It always caused depression with me. Finally Wellbutrin helped with that. I had been on it for a year and getting the diagnosis...was enough to have one final cigarette.

The most satisfying?

It is nice not to worry when or where you next smoke. I always smoked outside my home, but visiting non smoking places..was very trying.

Having allergy/asthma, there are a lot of things I have to do different from people with normal lungs. For one thing, I can't just go to other people's homes if they have pets or other things I'm allergic to. I can't go to my dad's cabin like the rest of the guys. I used to do those things, and I've learned I had to make this change in order to control my asthma. It's extremely hard. In fact, I think that's the hardest part of having a breathing disease other than losing your breath.
Have there been any life altering changes you've had to make? If so, (other than quitting smoking and having to get used to TTO) can you name at least three?

Taking sooooo long to leave the house, planning what O2 portable to use, how many tanks, when walking taking along water, I.D., cell phone, oximeter, stop watch, the law of the "leash" O2 tubing.

Getting used to a CPAP machine, and dedication to exercise...keeping moving as long and as fast as I can...which dumps the trapped air.

TTO...love it in spite of some rare complications...allergy to metal chain & keloids in incision (I was predisposed to them - took the chance)this is the most wonderful and efficient delivery of oxygen. You suddenly realize you missed "your face"...you get it back.

How hard was it to make these changes?

The supplemental oxygen was equal to Energy, made exercise easier to do. The tubing dragging around catching on everything-abominal. Finally I decided to pretend it is a puppy on a leash wanting to stop and sniff. you know love pets but hate their problem times, but deal with it anyway.

The CPAP-took about a month of pretty rough non-sleeping nights. Planning about oxygen to go is second nature now, doesn't mean I like it though.
Have you ever been admitted to the hospital for breathing difficulties?

No, only had high blood pressure spikes (my heart beat harder faster pressure up trying to oxygenate me when sats dropped to 70's...I didn't know at the time I had a problem

What was your most horrifying hospital experience?

Boy, have I been lucky...hmmm one shot felt like a dart being thrown into my hip.

Your favorite?

Eating food I didn't have to cook.

What did you learn from it?

With other various hospitalizations I learned to speak up, say what I needed, know ahead of time what my treatment and care would involve, then see it was done. Only hospitalized for Fast Tract TTO procedure and for a bronchoscopy, I consider these educational and interesting. Obviously no ER exacerbations for me...maybe because of all my extreme exercise .

I wrote a post about the five types of COPDers. Which type of COPDer are you? Do you think my description is close to accurate, or am I way off?

Bullous Emphysema minimal bronchitis & asthma factor, border line mild/moderate with a V/Q mismatch and diffusion problem.

When I was first learning about COPD I read of the 5 year average life time expectancy. I changed from an introverted shy bookworm to an outgoing talkative...wanting to learn all about it. I am going to TALK as much as I can, I am so big an advocate of exercise...I do it myself to the extreme, but hey, my numbers haven't changed for the worse in 6.5 years. Maybe a couple -normal degrees for the aging factor. The meds I use brought my numbers up (on paper, they would drop back without the meds). I am doing great, with LOTS of hard exertion and time consuming exercise to get there...worth every minute.going towards 7 years now. Exercise needs is a great excuse to not get housework done.

I have some really horrifying asthma stories I've shared on this blog. What was your worst COPD memory?

Worst horrifying to me experience was my first day of rehab class. We were sort of hit up the side of our heads - with a 2 x 4.

My RT said do you want good news or bad news first?

Give us the bad...You will die of terrible suffocation!!! I looked around in horror at dismayed teary eyed faces and decided she had something up her sleeve.

The good news? oh well, you will be given morphine so you won't feel it.

Then a long pregnant pause........

BUT, if you exercise you can slow the progression of the disease. 2 folks dropped out that day.
I vowed to beat it, I'd work my A$$ off. and I did, for years after rehab...right up to walking half marathons, using 15 liters of O2 pushed in 4 high flow tanks in a baby jogger stroller. Obviously no other physical limitations...a little hypertension is all.

What did you learn (if anything) from it?

Believe only half of what you see, and one - tenth of what you read. Always check the age of articles, and if it is a reliable source.

I'm sure you've met some pretty neat respiratory therapists, what is your impression of this profession? What is your favorite experience with an RT?

RT profession...while young and enthusiastic...great - - if schooled in current text books. Some mediocre ones just passing the day- not re education. those from the 'old' school are awful, believing the myth!. A great one Mark Mangus on line, and John Goodman RRT from Transtracheal systems...they both have family with lung Transplants so are exceptionally sensitive to patients.

I wrote a post called the seven benefits of having asthma a while back. Do you see any benefits to you having COPD? If so, what are they? Can you name at least benefits to having COPD?

My life, began over with giving up all my favorite occupations stopped (dusty, stinky chemicals, etc) The big benefit - I changed from a quiet introverted book worm to speaking out...a copd pulmonary rehab advocate. Never an athlete before, but now can walk HALF marathons...it took a few years to get physically fit to WALK it with loads of supplemental oxygen.
I have written many times that asthma has made me who I am today. In fact, if it weren't for my asthma I wouldn't be an RT, I wouldn't be blogging now, and I probably wouldn't have met my wife (she was an RN student who followed me at work). That said, if I could go back in time and change history so I wasn't born with asthma, I would be reluctant to do it. If you had an opportunity to go back in time, would you change anything? If so, what?

hmmm, if I could change my genetic predisposition to get inflamed lungs from dusty smelly triggers...that would be good.

I have benefited with the exercise so much and events opened up a whole new world to me that I enjoy...tho' at 71 right now I'm a little burned out after 3 Half marathons this year. Another one in October, hope I am up to it. I certainly won't expect to do 15 minute per mile like last year's Denver Half marathon where the stars & planets were in alignment...all the other 70 somethings were off running the full marathon and my competition were in their 80's...I scooped 1st place against normal folks...cool.

We learn in RT school that the #1 goal for treating COPD patients is to help them to continue to be productive members of society. Do you think this is a good goal? Have you been able to stay productive? If so, how do you achieve this?

Yes, keeping in with society is important. I am more so now than before, I help out with the ALA Colorado coalition, the Colorado COPD Connection and write many articles to all respiratory magazines...proud to say one even was in the AARC Times and another posted on LTOT websites. I was shocked into 'moving' to prove I would control my disease and maintain numbers - except for the aging factor...successful for going on 7 years, with fewer colds than before copd diagnosis.
I know you stay pretty active, and preach that people keep moving and exercise. I preach the same on my blogs. How important is exercise to the quality of your life as a COPDer or COPDers in general?

Extremely important, I was weak like a toddler from deconditioning before it was determined I needed supplemental oxygen 24/7. Not getting enough oxygen for a couple of years was sleeping my days away and became dreadfully weakened...thought it was old age.
I thought it was very interesting to learn you have transtracheal oxygen (TTO) How did you come to the decision to get it, and how has it made your life better?

I was asked early on if I wanted a tto but at first the idea of an extra hole in me was not acceptable

Would you recommend it? (I know you would, but I'm just asking anyway)

You bet, I wished I hadn't waited so long (3.5 years)..., I hoped it would lower my oxygen flow requirements, that makes portables last longer. It did by 50% of slow activities and somewhat for heavy exertion. At altitude and with my V/Q mismatch...going 4 mph I require 15 liters, only 10 for 3.5, and 6-8 at 3 mph...much depends if ground is level or a hill. Stair climbs & hills are major challenge.

Mike McBride is a friend of yours who also uses TTO. He participates in marathons using his oxygen, and pulls a cart carrying his oxygen supply behind him. Recently he participated in the Boston Marathon and he became the first oxygen dependent person ever to accomplish this feat. In your opinion, how significant is this to the COPD community?
It is a thrill, but we always have to say, that distance is not necessary for everyone...he likes walking, I do too, and we are somewhat extreme rising to meet challenges. We want to stay strong to care for ourselves and not become a burden to our loved ones. Some patients say "I can't" with many I think they like getting waited on and don't really want to put in the effort enough. What you put into it you get out of it-better functioning & definitely a superior quality of life.

You seem to be a rather optimistic and motivated person who makes a gallant effort to help others. I think that's great, and I think many COPDers out there benefit from what you do? One of the ways you do this is by spreading the word about TTO and sharing your COPD wisdom via your blog and COPD communities. What motivates you to do this?
I was helped at first on on-line support sites, saw how others went down the tubes, wouldn't listen or help themselves, this horrifies me.
Were you always interested in doing things to help others, or is it the benefits of COPD that inspire you to do this kind of thing?
Oxygen gave me energy to tackle moving a little more each day, I always have been a teacher (Aquatic director-teaching all ages- to swim, babies to lifeguard training. The pool chemicals-management probably didn't help lungs.

Is there any thing else you might want to share with my readers? Any words of wisdom I might have missed here in my questioning?
oh ...to the Respiratory professionals: your encouragement and help is extremely important...pleas know and be confident, patients are grateful though they may not say thank you. Be CONFIDENT you are the key to helping a person thrive with nudging them to move, use it or lose it. Be firm without being too too scary.
Patients ...take charge you can do more gradually improve day after day. Think only exercising one minute more each week adds almost an hour to what you start out with in a year.

What's your advice for young people considering having that first cigarette?
Don't do it, I point at my oxygen tanks, the visual of me walking by the high school...I hope impresses some to think twice.
What is your advice for people who just recently learned they have COPD?
CHOOSE what direction you want to take in life...up and better, or the downward spiral to pathetic dependency on others.then the simple eat-sleep-find meds to work for you, take charge of yourself and train your brain to like exercise - then do it...and of course, if you smoke work on stopping that and avoiding bad air of any kind...WASH HANDS, take a box of baby wipes in the car to use after being in a store..

I should have made this question #1. I got to know you through the COPD community here at Yahoo, or did you discover me first through my blog? I can't remember?

I saw your blog on the Google copd blog alert...the debunk the old myths topic.

Would you briefly describe for my audience who you are and what projects you are involved in?

Better they read this: http://www.copd-alert.com/LynCole.pdf. This is a good introduction to me from 2006 an that article in the COPD Digest. The blog address at the end is incorrect ...it should be http://profiles.yahoo.com/roxlyngcd

Since then now in 2009, I am 71, involved with 4 on-line support groups, I try to pick out folks in need of help with pulmonary rehab, or oxygen products..
My new passion is testing out products such as POC's, liquid oxygen portables, anything manufacturer's will let me try.then I write it up on my blog...the biggest day was about the ViaSpire liquid home fill unit...that brought in 1002 visitors on one day.
I am an AARC special member, a CSRC, NHOPA and ALACO (helped with the Colorado Copd Coalition), also active as a patient advisor with the Colorado COPD Connections group-we put on a conference each year. One is coming this Oct 3, 2009.
I write many articles about COPD rehab, TTO (Dr Petty calls it Necking with Oxygen", about testing from a patient's perspective, the walking events I participate in, and traveling with oxygen...published in AARC Times, Everything Respiratory magazine, COPD Digest, Breathing, ALA newsletters, NHOPA, and the Pulmonary Paper...also on line articles (see "A patient's perspective of POC's, Portable Oxygen Concentrators," By Roxlyn G. Cole, http://www.ltotnet.org/resources_patients_perspective_on_POCs.html)
Then of course my daily pul rehab & after blog.
Perhaps we've covered this already, but I'm going to ask it anyway. I explain to my readers all the time what it's like living with asthma. What's it like living with COPD?
I am most fortunate, having only mild/borderline moderate. and without the bronchitis factor. The adjustment was getting over being tied to an oxygen source...imagine being on a ball and chain, that you have to keep disentagled from catching on things, and always gauging how long you can stay out with the portable you have. It is a love hate arrangement. I love what the O2 does for me, hate the restrictions. You just have to deal with it and get over the initial roller coaster ride of emotions that goes with it...depression is normal at first. Tackle one problem at a time.
I'm going to ask you to speculate here. When I'm taking care of my COPD patients I always tell them I understand what they are going through because I've had bad asthma attacks many times? Do you think there is a difference between being short-of-breath with COPD as compared to asthma?
I have heard asthma is by far the worst than . the sob feeling isn't pleasant, but you can work to overcome - or at least deal with it. I think I had more discipline than most from life guard training, I don't panick easily...swimming also I think, increased my lung volume which is way over normal.

Last question. I think there is nothing worse than when you can't catch your breath. It's basically something you take for granted until it's not there, and when it's not there it's simply horrifying. It might even be worse than the worse pain. Would you agree with this assessment, or am I going overboard?
I don't think you are exaggerating, I haven't "visited that sensation...yet except when wind was knocked out of me from a fall on my back".
That is part of the reason I work so hard on walking and breathing, I don't want to "go there" or suffocate.
With COPD one wants to dump the trapped air so new air can be drawn in deeper. The longer the walk (with PLB) the better I feel afterward...the lungs that is, my muscles of course get tired.
I like the analogy of blowing to cool the soup on a spoon without spilling it, just a gentle back pressure, not as forceful as blowing out candles. AND getting the air in nose or mouth, it doesn't matter which way you draw it in!

Oops, one more. I became an RT because I knew I would have empathy for my short-of-breath patients because I was once one of them. Do you think that people who are RTs and have never been short-of-breath can be equally empathetic to chronic lungers like you and me?

I do wonder, they could simulate the sensation...the test needed is to do about 15 rigorous jumping jacks, pinch ones nose and try to do all breathing through a straw.
Another must in RT training (in my opinion) would be to wear a cannula 24/7 and lug around an oxygen portable...also at home see how it feels to walk around on 75' of tubing. THEN, you might get a tiny idea of how annoying and frustrating it can be. Try making a king size bed up with a long hose on...oh, that can be difficult until you learn to flip the hoses around. Learning to wear a CPAP is a challenge too...see attached photo of hubby & me, also one of my "lungs a la carte", then a chart of how different POC's worked for me. My findings actually were right in line with professional tester Robert McCoy.

Thanks Roxlyn! You taking the time to answer my questions has provided us with some great into a COPD mind.  And I'm sure all my readers appreciate you taking the time to do this. I know it's not easy, but any time a person can be as open as you about living with a disease everybody benefits.

Further Reading:

1. The hypoxic drive: completely debunked
2. The hypoxic drive: a history of the myth

New drug combo may greatly benefit COPDers

I had an uncle with COPD call me about a year ago because he wanted to learn ways he could improve his lung function. Basically, I gave him three recommendations off the top of my head:

1. Stop smoking

2. Stay as active as you possibly can

3. Take all your lung medicines exactly as prescribed

4. Talk to your doctor about Spiriva.

I told him I had read about studies that proved Spiriva improved lung function in COPD patients. He heeded my advice, but he passed away before I could talk to him about how it worked for him.

A new study released this past month shows not only does Spiriva improve lung function in COPD patients, if it is used in conjunction with Symbicort. According to an article at medicalnewstoday.com, the combination of Spiriva plus budesonide/formoterol combination (the contents of Symbicort):

• Reduced the rate of severe exacerbations by 62% (p<0.001)2
• Improved clinical lung function as measured by improvement in pre and post dose FEV1 (p<0.001,>
• Improved morning symptoms and activities (p<0.05)
• Improved health-related quality of life
• Was well tolerated

Typically, according to the above article, a combination of a long acting bronchodilator and corticosteroid and Spiriva is indicated in any COPD patient with a lung function (FEV1) of less than 50%.

So this is all the more reason to keep in touch with the latest research. If your doctor is unaware of this study, perhaps you'll want to nudge him.

However, keep in mind this is just one study, although one that showed significant improvements in lung function with those taking the trio of medications compared to those who received a placebo.

While there is no cure for COPD, the goal of therapy is to make sure all COPD patients are able to remain productive members of society. Aside from avoiding cigarette smoke and staying active, new medicines can help COPD patients accomplish the goal of maintaining a quality of life.

Does Ventolin benefit sleeping COPD patients?

This post is a special edition to "My Answer to your Rt Queries." This question was asked of me by an anonymous person who did not leave an email for me to resond to. However I think it is a common enough question that I am going to answer it in a public post.

QUESTION:

Hi-I found your site while cruising around the Internet looking for stuff about COPD.. Anyways your post here got me wondering --- I am caring for mom who was released from hospital last week under Hospice care (we are new to hospice). She has end stage COPD and she is soooo weak, barely eats or drinks now. I started giving her her nebulized Txs a couple days ago even though she is asleep all the time (I was waiting for her to be alert and awake and she still is not, so I felt bad and gave her Txs anyways. -Then when I read where you said something to the effect the pt wanted a neb tx even though she wasn't out of breath.. My mom hasn't been out of breath - do you think I should stop doing the neb at this point.. She was previously doing levalbuterol 4x a day.. Just wondering - any thoughts? - thanks! PS- hospice just always answers - "whatever she wants" - well I don't know what she wants because she doesn't wake up!

ANSWER:

Great question. One thing to know about Levalbuterol (Xoponex) and Albuterol (Ventolin, Proventil) is that most doctors agree with me that you cannot overdose on these meds. They are very safe bronchodilators that can very quickly provide relief for COPD and Asthma patients. I would imagine your mother took this medicine every four hours when she was awake because they provided some relief for her, and comfort. Of course now you don't know if your mother is short of breath or not, but it certainly cannot hurt her by continuing to give these treatments, and they may be of benefit. Of course I'm not a doctor, but I would say if the treatments benefited her while she was awake they will continue to benefit her now while she is sleeping, so it cannot hurt to continue them.

Just to make things interesting, I have always believed if a patient is sleeping they are obviously comfortable. I have had some families in this same situation decide to stop the breathing
treatments to no disadvantage to the patient.

So, based on all that I've written here, you can see that you can go either way, and I think that is why Hospice would say, "Whatever she wants." I actually think they are justified in saying that. They also could have said, "Whatever you think she needs for her comfort."

Personally, I'm not there to see what your mother is like, and I don't know how bad her COPD was before her current situation, so it's difficult for me to provide better advice for you. It is never easy making these kinds of decisions. However, I think your mother would be proud of you that you are doing this for her and thinking of her in this way. Whatever you decide is the right thing.

I'm featured on COPD News of the Day

This is respiratory therapy week. I remember one time in the past 11 years that my hospital celebrated this, and that was when the RT Cave made preparations and threw its own party.

To be honest, it's really not too big a deal, it's just nice to be noticed once in a while. I imagine that a certain level of appreciation is the whole purpose of weeks that celebrate a profession -- like RT week.

Plus, I think the fact that my hospital never misses an opportunity to celebrate RN week causes some RTs to feel left out when RT week is not celebrated, or at least some form of appreciation provided.

One thing we RTs know for sure, though, is that while our administration may not appreciate us, there is a certain core group of patients who do. A wise person once wrote that the greatest joys of life come from acts of giving or heroism that receive no reward. It's the pride in knowing you did something good that brings the greatest joy.

So when Karen Bastille emailed me and told me that she was going to celebrate RT week on her blog, COPD News of the Day, and that she wanted me to write a guest post, I was more than thrilled to write something for her.

Of course you guys know by now I am an asthmatic. When I was a kid I was a severe asthmatic. And, since the number of asthma patients has declined due to excellent education and scientific breakthroughs in medicine, the only patients left for me to empathize with are our COPDers.

I know for a fact that no group of patients appreciate their RTs more than emphysema and chronic bronchichitis (COPD) patients. And while some times they can be challenging, there is also no more enjoyable patient to care for than COPDers.

Just the other day I had a COPD patient who called for a treatment every two hours because he had coughing jags. Then sometimes he'd call for a treatment in between treatments because he rolled over in bed or had to pee and became dyspneic. In that sense, these patients can be a lot of work.

And then you have the clock watchers. These are the infamous COPD patients who watch the clock and demand that they have their breathing treatments every four hours on the DOT. If you are late, you will get a page.

Considering I work alone, I usually have enough respect for these patient to leave an extra amp of Albuterol or Xoponex or Duoneb with the patients nebulizer just in case I can't make it to their room. Usually I have the nurse give the treatment. Once I had a patient who insisted on giving himself a treatment.

While some are demanding, the majority of COPD patients love to talk. And, as an asthmatic who has gone through the short-of-breath process before, I understand why they love to talk.

I think there is nothing worse than not being able to breathe. If nothing else, this is the one basic part of life that 90% of us take for granted every day. We go about our lives, do what we do, and never think of breathing. That's the way it's supposed to be.

But then we become short of breath, and we are so miserable for so long, gasping and panting and concentrating on each heavy breathe praying that this will not be our last. You get to the point you can't even take in a quarter of a breath. You are completely miserable.

And then, all of a sudden, after a bronchodilator breathing treatment (or in my case when I was a kid an epinephrine shot), we can take in a nice deep and normal breath. Then you go through the vulnerable phase.

You assure yourself that you will do every thing right for now on. YOU NEVER WANT TO FEEL THAT MISERABLE AGAIN. But you know you will at some point.

You may even do something stupid like start smoking again, even though you insist while you are in the vulnerable phase that you won't. Or, like I did more than a few times before I finally learned my lesson the hard way, you might simply stop taking your medicines when you feel good.

The fact that you know this will happen again, and the fact that you felt so miserable and now feel so vulnerable, brings about this state of euphoria. You are just exceptionally happy. You are exceptionally productive after a short of breath episode.

I know this, because after I spend weeks in the hospital, I used to go home and have my home spotless in less than 24 hours, and then I'd spend hours writing in my journal telling my story because I had this unending desire to share my experience, to share my life story.

And that I think -- that euphoric feeling coupled with vulnerability -- is the reason that COPD patients love to talk. As an RT, I have learned more about the lives of COPD patients than any other. They want to share it all.

There have been many slow nights at Shoreline medical where I have stayed up late visiting with a friendly and talkative COPD patient.

So when Karen emailed me that she wanted me to write a guest post, I decided to write about one of my favorite all time COPD patients, who I think tends to be a composite character for most COPD patients.

Her name was Mrs. Flowers, and she was always working on a quilt. I have lost count of how many COPD patients I have had who constantly have a project going because they love life so much and want to share thier talents. But there have been many, just as there have been many-a-COPDer who loves to share his or her life experience.

So, click right here and I will morph you on over to COPD News of the Day. A great blog for COPD patients by a COPD patient who is doing a great thing by sharing her COPD wisdom.

Likewise, you can click here and you can read about the five different types of COPD patients.

Are we prolonging life, or delaying death???

What I am going to write about tonight is something we need to have a major discussion about. Because I am convinced there is no solution to this conundrum. It's a conundrum because this terminally ill 93-year-old do not resuscitate (DNR) patient was placed on a ventilator last night.

In talking to her daughter, she led a wonderful life. She never held a job in her life, but her husband had a good job, so she didn't have to work. Instead, she stayed home and took care of the kids.

She has four kids, and all of them became successful in their own right. She was so proud that all her children turned out so well. And she's even more proud of her 12 grandchildren and three great-grandchildren. The flowers all over her room are a testament to how much she was loved.

When she was diagnosed with pulmonary fibrosis (PF) at the age of 88 she decided to make herself a DNR. Yet, even before the PF diagnosis she had become a regular fixture in the hospital with fluid overload, whereas her doctor said to me once, "Even a slight weight gain of 1-2 pounds quite often put her into pulmonary edema."

She was also a lifelong smoker. As a matter of fact, she smoked about a pack of cigarettes a day since the mid 1940s, when she started because it was in fashion to do so. As one of the negative and unexpected consequences of smoking, she has slowly developed emphysema, which has now progressed so that she has become a CO2 retainer.

Considering her grim prognosis, her doctor and family had decided to make her a comfort measures only patient, which justified placing her on a non-rebreather to keep her oxygen levels up despite the fact she was a retainer. But, despite the high levels of oxygen needed, she did not stop breathing (despite what believers in the hypoxic drive theory might contend. but that's a discussion for another day.)

The family had already been informed that their mother probably wouldn't live much longer without getting her lungs cleaned out, and that the best way of doing that was via a bronch. Yet, if the bronch were to be done, their mother more than likely would have to be intubated. But with her extensive medical history, she probably would need to stay on the vent at least over the weekend.

After a brief family conference, the family made the difficult decision to go ahead and allow the surgeon to do the bronch and risk the vent.

While the anaesthesiologist used a minimal amount of sedatives during the procedure, the patients sats consistently stayed low even on 100% FiO2, and the patient was not breathing over the vent when provided the opportunity. So the choice was made to send the patient upstairs to critical care, and to call RT to set up a vent.

As you know, when someone has to go to surgery they wave their right to a ventilator, at least temporarily. Even while a bronch is a simple procedure, it involved placing a tube in her throat, and the doctor peeking around her lungs with a bronchoscope.

As I was setting up the vent, the surgeon told me the right lung was completely filled with pneumonia, and he suctioned copious amounts of thick brown pneumonia not just from the right lung but from the left lung too.

The poor lady. My initial impression was that I'd keep her on the vent a few hours and wait for her to wake up and hopefully extubate her by morning, as I would any other post-op patient. But then I learned the story I just reported to you.

The problem with this case, as the Internist reminded me when he arrived on the scene to manage the ventilator, is that this patient is not weanable. He said, "How do we wean someone off the vent to respect a DNR order when she was on 100% to begin with. I know she's a DNR, but how do we ethically get her off the vent?

This lady was a true medical and ethical conundrum.

Did the family make the right decision? If they did nothing, there mother probably would have died soon. If they did the bronch, it might be possible to resolve the pneumonia, but still, the chance of her ever leading a normal productive life is gone. She is frail and has a terminal illness.

While the family assured me that they perfectly understand modern medicine cannot stop the inevitable, it might buy her some time, "so she can make it to her grandson's wedding in June."

Still, as one of the doctors said to me afterwords, "Are we prolonging life, or delaying death?" That is the question up for debate. What do you think? What would you do?

No Vent, DNR, or full code: what's your choice?

The decision of whether or not you want to be placed on a ventilator, or whether or not you want to make a decision for your loved one, is one of the most difficult decisions one can make. In fact, this is the basis of some very deep ethical discussions, and one of which may never be answered by society, only by the person who has to actually make that decision.

First let us note here that a majority of patients who go on a ventilator do so only for temporary purposes. If you have surgery, if you have severe asthma, pneumonia, or failing heart, you may need to be placed on a ventilator short term, just to get over the hump, per se. If a person is involved in a trauma, or if CPR is performed, then a person may be intubated and placed on a ventilator.

Those are easy decisions, especially when we are in emergent situations and are trying to save a life. However, there are also times when the decision to intubate or not to intubate can be complicated as complicated can get, and very stressful, and often disappointing if not discouraging.

In some cases you can plan ahead and write in your advanced directives that you do not want to be placed on a vent.  However, sometimes I have seen this declaration over-ruled at the point of impact when a person is in the emergency room and the person has to decide, "Do I want to risk dying now, or do I want to let these good people here in the emergency room help me breathe by placing a tube into my airway and assisting me with my breathing? Do I want to do that?"  More than likely, it will be, "Do I want mom or dad or grandma to die?"

Here I will provide some examples for you. All of these come from real life examples as I have actually seen them in my eleven years as a registered respiratory therapist.

One of the most frustrating examples to me was when a person decided they did not want to be placed on life support because, "I don't want to spend the rest of my life on one of those things," or "because I don't want to become a vegetable." In thinking this way, many people choose the following in their advanced directives: Full Code, Do Not Vent, or Do Not Intubate.

I have to cringe when I see that. I cannot believe any lawyer or doctor -- or advisor -- would recommend that option, because when a person's heart stops, and we have to do CPR on the patient, we also have to pump in quite a bit of medicine, and 99.9% of the time the patient does not survive a code breathing on his own: he has to be intubated and placed on a ventilator. Thus, if we do CPR, we have to put you on a vent -- there is no other option.

What might confuse people is what you see in the movies. There was one episode of "Walker, Texas Ranger," where Chuck Norris's character was having chest compressions performed on him, and his friend who broke his arm was watching on. Then Chuck woke up, the ambulance arrived, and the person who was taken away on the ambulance was not Chuck, but Chuck's friend with the broken arm.

It does not work this way in real life. The majority of the time when CPR is done on a person, that person buys himself a ventilator. That is, unless you are a DNR. In short, DNR means Do Not Resuscitate. That means if your heart stops we will not try to restart it. And, if you stop breathing, we will not place you on a ventilator. We will let nature take its course.

However, if the people working on you don't know you are a DNR, you will end up on a vent regardless. Not only is that the ethical thing to do, it's the law. If you're going to err, you err on the side of life.

However, I do think the decision not to become a vegetable on a vent is a valid issue for most people. Yet, one also has to consider the definition of a vegetable. Are you a vegetable when you have no body, but your brain is fully functional (as would be the case Lou Gehrig's Disease).  Or are you considered a vegetable when your brain if officially declared dead but your body continues to life?

Some people value life so much that they would want to live so long as they have control of their brain. That was my grandmas wishes when she was diagnosed with multi system atrophy, a disease similar to Lou Gehrig's Disease.  As a pro-life advocate, I totally supported her decision.

However, there was also the issue of depression and humiliation as you are fully aware that you have a tube up every orifice, and some strange person wiping you every time you have a bowel movement. Not only that, but you have to have someone assist you every time you move anywhere. Basically, you are a mind without a body. Do you want to live like that? Do you value life that much? Some people do. And we medical workers respect that.

Then you have the people who have Alzheimer's. These people will have fully functioning bodies but no mind. No mind no matter, no matter no mind. I would imagine that this might be the best way to end your life on a ventilator, if one had to choose between the two.

If I were an elderly person diagnosed with Alzheimer's, I would simply make a wish to be a DNR just so that I wouldn't become a ward of the state, a useless blob of skin on a bed taking up space and absorbing taxpayers money.

However, that would be my decision. I have to respect the wishes of others who think otherwise. Thus, life is very precious no matter how fragile, and each individual has to decide for himself. Grandma should be allowed to  choose for herself how she wants to die. This is why it is so important for physicians to be honest with their patients and talk to them about end of life options.

Then, let us consider the COPD patient who decides that he does not want to be placed on a ventilator. He is not necessarily end stage, but he is to the point that he cannot go without using his oxygen. However, he has a quality life to the extent that he is not one of those people who simply sits around and feels sorry for himself. He loves life. He loves living.  Yet he was also scared by the prospect that he might be placed on a ventilator and have to stay on it the rest of his life. So he makes the decision one day that he will make himself a dd not vent patient.

Then one day he is having trouble breathing. His wife drives him to the hospital and by the time he arrives there he is severely short-of-breath; his work of breathing is labored. The doctor looked the patient straight in the eyes and asked the question no one wants to ever hear: "If something happens to you, do you want to be placed on a ventilator?"

Of course now the patient is not in the planning stages. He is actually miserable, gasping for every breath. His oxygen levels are falling. His CO2 levels are rising. He is pooping out. He has a feeling of impending doom. He, however, does not want to die; he is not quite ready.

Then again, he does not want to go on one of those things either; he does not want to be intubated.

So, he asks the naive question that is really not so naive because the only people who truly knew the answer were standing in the bright room around him. Of course there were other COPD patients who knew the answer, but they were not in the room. His life, his destiny, was in the hands of the fine medical workers in the room.

"So," he says, huffing and puffing, barely able to get the words out, "How long would I have to be intubated for?"

"Well, the goal would be a day or two, but we really can't guarantee," the doctor explained. Of course she doesn't want to give false hope, but she also doesn't want the patient to simply give up hope at the same time. This is the ironic twist that we often face in the emergency room. She continued: "The goal is basically to rest your lungs and allow them a chance to heal. That's the goal. I can't guarantee anything, but that's the goal."

I stand there thinking, as I am getting my intubation equipment ready just in case the patient makes the decision, that the doctor made a good presentation. In fact, I couldn't have worded it better myself. The key words there were help you get over the hump and I can't guarantee anything.

By these short phrases the doctor threw the ball completely in the patient's corner. And, if the patient were to pass out, into the wife's corner. And if the wife were not there, the medical staff would have no choice but to make the patient a full code and do everything for the patient, unless they were 100% positive the patient was a DNR.

Another case I've seen is the elderly man with a chronically failing heart come into the hospital in respiratory failure secondary to the failing heart. The patient is non-responsive, and he is also not a declared DNR. The wife now is forced to make the decision of whether or not to allow nature to take its course, or to allow the medical staff to intubate her husband and place him on a vent.

"What should I do?" the patient's wife asks the Doctor.

"Well," the doctor says, "I know this is a difficult decision. Since you are in a very stressful situation right now and you want to make sure you don't make the wrong decision, perhaps it would be best to let us intubate your dad, and you can see how things progress, allowing yourself some time to spend with your family and to think. Then, in 24 hours or so, you can see how things are going with your dad. Either way, I can't make any promises. It's your decision."

The doctor pauses, allowing the patient time to think.  He then says, "Technically speaking, the goal of going on a vent is short term therapy to allow your husband's heart and lungs to rest. If things work out, he might come off in a day or two. However, I can't honestly say those odds are very likely right now. But, if things don't work out, he very well could be dependent, that's always a possibility. But if it comes to that, you can make a decision to terminate the vent if you wish."

After another pause, the doctor solemnly states, "However, if he doesn't go on a vent now, there is very little chance he will survive this."

Yes!  That was so true. The doctor was very honest with the patient.  He did was was necessary.

In this case, the wife decided to place her husband on the vent and the patient came off two days later with full mental capacity. Of course he was limited in what he could do, and had to go home with oxygen. And while his heart remained severely fragile, he was able to spend another two years with his family.

Thus going on a vent to get over the hump bought this man two years to say good-bye to those he loved, and allowed those he loved to say good-bye to him.

I talked to the wife a year after he died, she told me she was very pleased with her decision to place her husband on the vent. She said her dad was also very pleased.

One time we had a lady on a ventilator with ARDS, and as she was on the vent for the fourth week. It was becoming evident that she wasn't going to make it. The patient had already been given a slim 10-20% chance of surviving by the doctor.

But the family stood firm with their hope, and prayed the patient would not only come off the vent but have some quality of life thereafter. Even the family was starting to give up hope after a while, though. Then one day, as though by some miracle, the patient woke up and was eventually discharged.

I know that's a rare instance, but patients with grim chances of survival can survive. And while it might be fine to say, "I've seen people like this survive before," you still don't want to give a family member false hope.

Likewise, I have seen many cases similar to my above examples go in different directions. In the medical field, you just never know what's going to happen. And, when you are making end of life decisions, you never know what the right answer is.

There are times, though, where I would definitely recommend a DNR status. These would be elderly people over 90, and any person who has a terminal end stage illness. If you have an 80 year old lady dying of cancer, it would be kind of foolish to place that person on a vent, when all the vent would do is delay the inevitable, and cost the family insurance and taxpayers thousands of dollars in the process. I'm not saying that money is more valuable than life, I'm not saying that at all.  What I'm saying is that sometimes it's just noble to let nature take its course.

Yet, I see these people going on ventilators all the time. In many cases it becomes quite frustrating to see these people on the vent for weeks on end. And, this can quite possibly be one of the most frustrating parts of the medical field. Sometimes I even feel sorry for these people, especially when it appears to me they are trying to die, and their family members keep pushing for them to live.

Recently I placed a cerebral palsy patient on a ventilator. He is off now and back at home in the care of his family. The quality of life for this person was already pretty low, but the family loved this young man and truly valued the sanctity of life. We had to respect those wishes, and we took care of him as we would any other patient.

So, if you are wondering whether or not you want to be a full code or DNR, or whether or not you want to go on a ventilator should your body start to fail you, you should take some time to consider the what ifs.
It might be a difficult thing to stop and think about, but it could save you and/or your family members a ton of grief and stress.  It would help you and your family prepare for the end.  It would help you die with grace and dignity.  It would let you decide how you want to die.

As you can see, this is not an easy subject matter for anyone, including us in the medical field. And this has been and will continue to be an important ethical discussion for years to come, especially as we live in a world where we have the means to prolong life.

What's it like to be intubated?

As I was looking at my blog statistics, and checking the recent keyword activity that landed someone on my site, I noticed one person had typed in the query, "What's it like to be intubated."

I remember waking up from a surgery once, and this person pulling something out of my mouth. I had no idea until I went to RT school what had actually transpired at that moment: I was being extubated.

So because I was medicated, I had no memory of being intubated, and had no memory of my time on the vent during the surgery. Thankfully, I must add, I have no memory.

Fortunately, I think that is the case for most people who are intubated. I think that we keep them sedated enough that they do not remember much. However, on occasion, we do have to intubate people under emergency situations where there is no time to medicate the person, and usually that person gags and groans during the process. There is no doubting the this is not a pleasant procedure to have done.

Which is why Succiconine is such a great drug, because it paralyzes a person just long enough to get the job done. And then, while the patient is serving time with a ventilator doing all the breathing or assisting with it, a patient is sedated enough with some good meds to allow the person to rest comfortably. And, while the patient is often awake, the meds are good at causing amnesia.

Lots of times I have to communicate with a person on a vent. Of course they can't talk, but you get pretty accustomed to lip reading after a while. Then, a few days after the patient is over the hump and is extubated, you ask them if they remember being on the vent, and they will tell you they have no memory of it. That's not always the case, but most of the time it is.

Occasionally, a patient remembers everything. Some patients are awake, alert and orientated the entire time they are on a vent. It's these people where you can learn the most from of what it's really like to be intubated.

It doesn't always suck either. I remember this one chronic end-stage COPD patient who was extremely short-of-breath. She told me she felt like she was suffocating. The next time I saw her she was on a vent, and she looked at me with eyes of joy. She smiled. She took in a deep comfortable breath. That vent was her savior.

That patient did not want to get off that vent.

I like to explain to my vent patients, if they are at all comprehensive, that they have not been placed on a ventilator permanently, it's just short term until their lungs get better. It's more or less to allow their bodies time to get over the hump. That's the case most of the time. And, usually, the person is off the vent in a day or two.

While I can honestly say that I have experienced much of the things I do for patients on a daily basis, I have never been on a vent; and I have never been suctioned.

One of my co-workers and good friends and fellow asthmatic was placed on a vent once, and she said she remembers the whole thing. She remembers being awake and alert and looking out the window and seeing a Burger King, which sucked because she was starving. And, she said, that wasn't even the worse part. The worse part was getting suctioned. She said there is absolutely nothing worse than that.

That in mind, a fellow blogger who used to be an RT, and who is unfortunately a victim of severe persistent asthma, was placed on a ventilator recently. I thought his story was very inspiring, and I would like to link you to his blog: The Bay City Walker.

The five different types of COPD patients

In RT school we are taught that there are three different types of COPD patients: emphysema, chronic bronchitis and asthma.

In the hospital we tend to leave asthma out of the COPD definition, and the general consensus is that if they smoke it's not asthma.

However, some doctors still diagnose smokers with asthma. I suppose that's their prerogative.

Personally, I am under the belief that if you are an adult with asthma, it is chronic asthma, and falls under the category of COPD.

Emphysema patients are referred to as pink puffers, because they tend to have smaller frames are are not cyanotic. Chronic bronchitis patients are referred to as blue bloaters, because they tend to have larger frames and are often cyanotic.

However you want to define COPD patients that's up to you. Based on my experience working with COPD patients over the years, I have come up with a list of the five different types:

Happy: About 80% of COPDers fit this category. These patients tend to be among the most pleasant of all patients, more so because they are professional patients with a chronic illness and have accepted it. They rarely ask, "Why me?" Happy COPDers generally are of two types: they are either talkative or phlegmatic.

Talkative: About 80% of Happy COPDers are talkative. Some of the best conversations I've ever had with a patient have been with a talkative COPDer. Before their "time is up" they want to share as much of their experiences and knowledge as possible.

When you give a treatment to one of these patients they might not let you leave. They will talk openly about their illness and family life. By the time the patient is discharged you will have a pretty good idea of what kind of a person he was, and what kind of a life he led, prior to getting sick. Usually they are very interesting and intelligent.

If you are talking with a COPD patient, and the patient starts describing an event that occurred in 1945, he is probably a talkative COPDer.

Phlegmatic: About 20% of Happy COPDers are phlegmatic. Whatever you want to do, they don't care. They talk little and have very pleasant and modest dispositions. The majority tend to be men.

If you walk into the room and find the patient has his feet up on the end table while watching TV, you know he is a phlegmatic

If you walk into the room and find the patient is moderately labored and still appears cool and calm, he is most probably a phlegmatic.

Melancholy: About 20% of COPDers fall into this category. They love to be waited on hand and foot. These patients have not accepted that they are sick, and have a tendency to be unpleasant
and very bossy.

When this patient wants a drink, she will say something blunt like, "Drink!" or, "Gimme a drink." Many might pretend they are incapable of lifting the glass so you have to do it for them. If you hear the words like please or thank you, you are probably not dealing with a melancholy COPDer.

Exaggerated: Would you believe it if I told you that a certain percentage of patients actually WANT to be in the hospital. The exact percentage is unknown, but it is estimated to be around 20%, and includes both Happy and Grumpy COPDers.

What happens here is that family members are tired and need a break, so the patient feigns his symptoms to get admitted.

If you need to give a series of Duoneb treatments in ER, but once the patient is on the floor she declines a treatment because she wants to sleep, then you should think exaggeration.

If she is lying in low fowlers and appears to be in no respiratory distress when you walk into the room, but as soon as you grab your stethoscope you hear an audible forced expiratory wheeze, you should think exaggeration.

If she is so bored the day after her admission that she is assisting her elderly room mate walk to the bathroom, then you should think exaggeration.

There are two different types of exaggeration of COPD. When emphysema and chronic bronchitis patients are faking it, the diagnosis is generally exaggeration of COPD. Faking asthma patients are referred to as exaggeration of asthma.

It is important that exaggeration of COPD not be confused with exaggeration of asthma. The differences may not be easily identified once the patient is in the hospital, but must be obtained through questioning, or it may simply be assumed.

Now, I know your science teacher told you not to assume, because when you assume you make an A-S-S out of U and ME. But in this rare instance, it is often necessary in order to make a proper diagnosis of the type of COPDer.

Exaggeration of COPD is when the patient is faking because their family members taking care of them are tired and need a break. So it may be assumed that 100% of exaggeration of COPD patients do not come from nursing homes or assisted living centers.

Exaggeration of Asthma is when the patient is faking because he is stressed and in need of a break from his family. He loves it that when he comes to the hospital he receives special attention and sympathy, and gets waited on hand and foot.

Now, while most of my opinion in establishing this data was obtained at one small town hospital, I believe my sample size and length of study (12 years) was large enough to obtain an accurate stereotype of all COPDers.

However, it must be noted that their is a +/- 6% margin of error on my percentages.

If you disagree with this assessment, or you have an observation of your own, please feel free to let this RT know.

See the 11 types of asthma patients