Can you vacuum your carpet when on oxygen 24/7?

Each week I take time to answer questions from my readers. This weeks question comes from a COPD/heart failure patient who is new to using home oxygen.

Your Question: Can you vacuum your carpet when on oxygen 24 7. Please somebody help and tell me if you can or not.

My humble answer: Great question! Yes, you can vacuum while wearing oxygen. It's a great way to stay active, and it feels good to accomplish something like cleaning your home. Just be sure to keep safety in mind: keep your oxygen equipment away from the vacuum, be mindful of your tubing to prevent tangling, and make sure your vacuum is in good working order to avoid any sparks. It’s also a good idea to keep the room well-ventilated if you're using an oxygen concentrator. Stay safe and keep moving!

Why Is Adult-Onset Asthma More Severe Than Childhood-Onset Asthma

Your question: Is it known why late-onset/adult-onset asthma harder to treat and control?

My humble answer:  I have done lots of research into differences between childhood and adult-onset asthma. While there may be a variety of theories (guesses) explaining this, I think there is one that sums it up best. One theory says that the differences in childhood and adult onset asthma is the type of airway inflammation that is present. A few years ago, one allergist told me that nearly 100% of childhood-onset asthma is allergic, and so they tend to have Th2 inflammation (https://asthma.net/living/th2-dominant-asthma). And this type of inflammation responds very well to traditional asthma medicines (bronchodilators, corticosteroids, etc.). Those with adult-onset asthma tend to have different types of airway inflammation that tends to be stubborn and more resistant to traditional asthma medicines -- making them more difficult to control. Good examples here are eosinophilic asthma (https://asthma.net/living/persistent-eosinophilic) and neutrophilic asthma (https://asthma.net/living/subgroups-the-basics-of-neutrophilic) -- both of which are more likely to occur in adults than children. Actually, another article you may find helpful is this one (https://asthma.net/living/subgroups-the-basics-of-neutrophilic). 

What's it like having a defibrillator?

Your question. What's it like having a defibrillator? Does it shock you a lot?

My answer. I have had a few patients with defibrillators. Although, I think this answer would come best from someone who has a defibrillator. Obviously, to get one is a very stressful decision. But, it certainly beats the alternative. And it has helped so many live longer and better despite a heart condition. That said, below is an answer from someone living with one.

A patient's answer.  "No it has not shocked me yet. It's also a pacemaker. It's paced my heart several times but I don't feel it. If the defibrillator goes off its because my heart stopped or gone into severe arrhythmia. Then I will feel it. I hear it's like getting kicked by a horse. Hopefully I'm unconscious by then. It will probably go off if I have a seizure. I just make sure I stay on my medicines. It's all good!

Why Don't Inhalers just Have Refills

Your Question. Why do pharmaceuticals companies use so much plastic. I could easily use my rescue inhaler delivery piece on more than one canister of albuterol. I clean it frequently anyway, especially now! One pump device for every three canisters or so would save a lot of waste...and COST!

My answer. That is a great point that you make. I have raised that myself to a pharmaceutical rep a time or two. That argument the other way is that pharmaceuticals want to make sure you have access to the whole inhaler when you pick up a new one. They don't want to assume a person has the medicine but no inhaler device to deliver it with. i think the general consensus is this makes it easier for asthmatics. Although, I do tend to agree with you. It would be a neat thing to advocate for if that was something you'd be interested in doing. 

Do Generic inhalers Work As Well As Brand named inhalers?

Your question. Do generic inhalers work as well as brand name inhalers.

A pharmacists answer. I am a pharmacist with asthma. The rescue inhalers generic name Albuterol don't work the same for all asthmatics. Brand name Ventolin and Proventil works best for me. However Qvar now has a generic and it does not work for me. If my prescription says 1 to 2 puffs every 6 hours prn. On Qvar I would have to do 2 to 4 puffs for relief. Generally we are taught in school that the generic drug works the same and in this case these branded albuterols work the same but they don't in all patients.

It's very important to monitor yourself when switching to a different product due to formulary changes to make sure it works for you specifically.Most people that had asthma for years know when and inhaler opens them up or not.

My answer. T It's neat to get a pharmacists take on this subject. I have always wondered about this, as many of my asthma friends have said that some generics don't work as well for them. I personally haven't noticed a difference in the different albuterol inhalers (other than taste). But i do know that some ICS/ LABA combination inhalers work better than others. I think most of us asthmatics find a rescue-controller brand that works best for us, only having to switch due to what our Insurance companies will pay for.

Sometimes my doctor prescribes one medicine and my insurance company wants to pay for another. This happened with me a few years back with Advair. My insurance company wanted me to switch to Symbicort. I did not want to. So, my doctor wrote a letter to my insurance company stating that Advair works for me (and that I tried Symbicort and it had too strong side effects for me). I have since made the switch, but so long as my doctors wrote those letters I was able to get the medicine of my choice. 

Do inhaled Steroids Damage Airways

Your question.  "I have a question about how steroids effect the lining of the lungs long term (by using steroidal inhalers. When steroid creams are used on the skin, over time the skin becomes thinner, is there any similar effect on the lining of the lungs?"

My answer.  Great question.  Corticosteroids have been around since the 1950s. They have been used for a variety of reasons due to the fact they decrease inflammation and therefore benefit many of our modern diseases. Corticosteroid creams can be used to reduce inflammation and itching and redness of the skin. When this is done it is directly applied to the skin with salves and lotions. In a similar way, systemic corticosteroids (like prednisone) reduce inflammation inside your body. This helps reduce airway inflammation so you can obtain good asthma control. Both corticosteroid creams and systemic steroids must be used short-term only due to risk of long-term side effects, such as thinning skin as you mention.

Inhaled corticosteroids are a different story. Because they are applied directly to the airways, a very, very, very low dose is needed. This low dose is sprinkled on airways. Using them every day has shown to reduce airway inflammation to control asthma. They have now been used for the treatment of asthma since the 1960s. So, they have been extensively studied for nearly 70 years. it has been determined there is a sight risk for side effects, although these are are considered negligible and treatable when they do occur. You can see this by the articles in this link: (https://asthma.net/?s=corticosteroid%2C+side+effect). The impact of this very low dose of ICS on your airways has also been extensively studied. It has been determined that ICS do not cause thinning of airway tissue. 

Sorry for the long answer, but I thought it would be beneficial to show it in perspective. As always, the side effects of any medicine are aways weighted against the risk of potential side effects. Poor asthma control can have a definite negative impact on the quality of your life. So, researchers, for over 50 years now, have recommended ICS as a safe and effective treatment for asthma. 

Does that answer your question

Should Insurance Companies Pay For Expensive Biologics?

Your question. Biologics are expensive. Xolair costs $1000 plus per infusion. The same is true for Fasenra, Nucala, and Dupixent. Many insurance companies will only pay for one or the other. This may benefit some asthmatics. But it won't help asthmatics who might benefit from one of the other biologics. So, what do you think about insurance companies not paying for or not paying for biologics for asthma?

My answer. I like to think that the long-term costs of poor asthma control would be way more than the short-term cost of any medicine. In this way, the short-term cost of a medicine would be way less than the long-term costs of poor asthma control. Insurance companies must think this way when deciding whether or not to pay for expensive medicines like biologics. All of these medicines are expensive. They all involve more than one expensive infusion. Still, they all have limits on the number of infusions you need. If one of these biologics works to help an asthmatic gain good asthma control, then you'd think that would bode well for the insurance company too. So, paying for biologics is a win win for both the patient and insurance company. Now, surely there will be the asthmatic who tries all biologics and none work. But, I would think this would be the exception more so than the rule.

There are definitely strict qualifications for insurance companies paying for biologics. At the present time, 100% of them are effective for eosinophilic asthma. So, to qualify, traditional asthma treatments with inhaled corticosteroids and combination inhalers like Symbicort and Advair must have been tried and failed. You also must be diagnosed with eosinophilic asthma. To be diagnosed, all that is needed is a high eosinophil level. The test is a simple blood test for eosinophils. If your eosinophil level is greater the 2, you qualify.

Xolair may benefit people with allergic asthma. Since allergic asthma is the most common subgroup of asthma, and because Xolair has been on the market now a long time, most insurance companies will pay for Xolair. Although, I am sure there are exceptions.

So, that is my take on your question. What do you think?

Are Asthmatics At Increased Risk Of Getting COVID-19

Question. Am I more likely to get the COVID-19 Virus compared to non-asthmatics?

Answer. Probably not. There is no evidence suggesting asthmatics are at greater risk than non-asthmatics of getting the COVID-19 virus. Still, there are precautions you can do to lower your risk. 

Reference.

1. McCall, Rosie, "Does Coronovirus Affect Asthma? What Sufferers Need To Know About Covid-19," Newsweek, 2j020, March 18, https://www.newsweek.com/does-coronavirus-affect-asthma-what-sufferers-need-know-about-covid-19-1493022, accessed 3/31/20

Should I stop using nebulizers as to not spread COVID-19?

Your Question. Should I stop using my nebulizer so I don't spread the virus?

My humble answer You do not have to stop using nebulizers at home. Nebulizers do aerosolize medicine. They also aerosolize any germs you might have, including COVID-19. This is a concern in the hospital setting, as healthcare workers in the same room as the person getting the treatment have an increased risk of inhaling COVID-19 during and for an hour after a nebulizer breathing treatment. To reduce this risk, most hospitals are using inhalers instead. This is not an issue at your home. You should continue taking your medicine (including nebulized medicine) as you have been prescribed.

Is There A Shortage Of Asthma Inhalers

Your Question. Are their any shortages of asthma meds due to dr's using them on Coronavirus patients. Are we safe at this point from these meds being hoarded?

My Humble Answer. HI. Thanks for the question. At the present time, hospitals have cut down on the use of nebulizers for COVID-19 or suspected COVID-19 patients due to the threat of aerosolizing the virus. So the use of albuterol inhalers in the hospital setting has increased due to the COVID-19 outbreak. For this reason, some areas are seeing a shortage of albuterol inhalers. At the present time, I believe this is the only inhaler affected. Albuterol solution for nebulizers should still be available. Does this answer your question.

Does Room Air Oxygen Cause Lung Cancer?

Your Question: You mentioned in your post "What is oxidative stress?" that inside the body oxygen breaks down into single molecules with unpaired electrons. They in turn become free radicals. Surely these free radicals can be neutralized with antioxidants. But you wrote that oxidative stress may cause lung cancer. So, does oxygen itself cause lung cancer?

My answer. To answer your question, under normal circumstances, oxygen by itself does not cause cancer. As it turns into free radicals, there are plenty of antioxidants available to neutralize it. So, under normal circumstances, the 21% oxygen in room air will not increase your risk for developing oxidative stress nor increase your risk for lung cancer.

However, inhaling supplemental oxygen can increase your risk of overwhelming antioxidants. In these situations, the risk of oxidative stress is increased along with the cancer risk. Things that might cause oxidative stress like this are abnormal circumstances, such as inhaling supplemental oxygen long-term or inhaling high doses of oxygen short-term. Certain disease processes (such as COPD) can cause it. Aging may change your internal environment in such a way as to cause oxidative stress.

So, to answer your question, inhaling room air oxygen should not increase your risk for developing cancer. And, I would surmise, as more is learned on this, only people with certain genetic predispositions at risk for developing cancers even in the presence of oxidative stress. So, there is so little known about this at the present time. It will be neat to see what researchers learn in the coming years.

References.

1. Reuter, et al., "Oxidative stress, inflammation, cancer: How are they linked?" Free Radical Biology & Medicine, 2011, December 1, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2990475/, accessed 8/19/19

My Doctor And ER Doctor Gave Different Diagnosis's

Your Question. My Doctor And ER Doctor Gave Different Diagnosis's
My lung doctor diagnosed me with small airway disease, but also told me I don't have asthma. But Iv been having trouble with my lungs on and off for a couple years. When I went to the ER they told me I do have asthma. So what is the difference or is there?

My Answer. This is a very good question. Asthma is the most likely culprit for certain symptoms, so it's normal for ER doctors to go with this most common diagnosis and treat symptoms as though this were the issue. If this solves the symptoms, then the said diagnosis is usually not questioned.

Still, your primary doctor is the one who assesses you on a regular basis and would be the one to give you the most specific, most accurate, diagnosis. So, what I would do, is talk to your primary doctor and ask specifically what he or she means by small airway disease. Sometimes it refers to asthma, although asthma that affects the smallest airways.

But, sometimes it refers to other less common diseases that are not well known. Getting to that specific diagnosis may be what helps you get the best treatment for your symptoms. So, definitely talk to your doctor about this. Hope this helps.

Your Question: Can you provide more information on small airway diseases? 

My answer. There are different diseases that can affect the smallest airways. One of these diseases is asthma. Keep in mind that your bronchioles are your small airways. They are 0.5 microns in diameter. Asthma attacks cause these airways to become narrow. This is due to a combination of bronchospasm and increased mucus production. Both work to obstruct, but not completely block, airways.

Your smallest airways are the next generation of bronchioles. These airways are 0.2 microns in diameter. Asthma may or may not affect these smallest airways. When it does it may completely block them. This can definitely make you feel short of breath. But, asthma may not completely block them

So, if this is the case, it's asthma. A problem here is that small airway obstructions may not affect the flow of air detected by peak flow meters and PFT testing. In other words, it's possible for you to have a normal lung function. But, you will be short of breath.

There are also other diseases that can affect your lowest airways. One is COPD. Another is bronchiolitis. And both involve airway wall inflammation. The cause is somewhat different. The treatment may be the same for asthma. And that may explain why systemic corticosteroids helped to reverse the symptoms. I'm assuming corticosteroids here as that is the #1 most common medicine for treating asthma exacerbations in the ER. If your doctor is thinking asthma, then the treatment is corticosteroids.

This same medicine may also help with these other diseases affecting the lowest airways. But, if you want to treat these symptoms long-term, you will want to get to a most specific diagnosis. Asthma can be almost definitively ruled in or out by having you undergo some tests.

The most common of which is a PFT test. So, for one reason or another, your doctor thinks you don't have asthma, then he may make an educated guess (which is what doctors sometimes are left to) and determine that you have small airway disease. Now, keep in mind here what I said above about how asthma in the smallest airways may not show up on a peak flow or PFT. So, in this case, a doctor would have to rely on other tests to get to a proper diagnosis.

In your specific instance, it's impossible to know what your doctor is referring to. Do you have asthma? Do you have bronchiolitis? Do you have COPD? Do you have some other less known small airway disease? That's a question I would reserve for your doctor.

Hope this helps. John.

Attached below are a couple articles you may refer to.

1. Pathology Of Small Airway Disease
2. Small Airway Disease, Excluding Asthma And COPD

Should You Use A Spacer With Symbicort

Your Question. If you read the package insert for Symbicort, it says not to use with a spacer. What should we make of this? It seems to me that common sense would point to using a spacer with it, considering it is an inhaler. What do you think?

My Answer. That is a very good question. There are actually two ways of looking at this.

One, that Symbicort is still a relatively new product, and it has yet to have been studied with a spacer. For this reason, their lawyers may require them to make this note on the package insert.

Two, the dose of medicine is adjusted based on estimated distribution to the airways. It is well known
that only 9% of medicine inhaled by metered dose inhalers makes it to the lower airways where it is needed. To compensate for this low distribution percentage, the dose of Symbicort was adjusted to obtain maximal results. Wanting to limit side effects, the makers of Symbicort (AstraZeneca) and their lawyers decided to put the disclaimer on the package insert that a spacer should not be used.

So, you might be thinking, so why then should you not use a spacer? The general thinking is that a spacer would improve coordination, reduce side effects, and improve distribution. A spacer will surely reduce impaction of medicine particles in your upper airway, thereby reducing side effects. However, these medicine particles cause systemic side effects only after they are swallowed. These medicine particles are broken down (metabolized) by the liver, where almost all of them are excreted in urine. Only a tiny fraction gets into your bloodstream and has a chance to cause systemic side effects. This is called first pass metabolism, meaning that your digestive tract and liver significantly breaks down the medicine before it reaches your circulation.

Now, let's look at the medicine that makes it to your airways. Studies show that 10-40% of this medicine will come into contact with blood vessels in your lungs. If you use a spacer and increase lung distribution, that means that you are getting more medicine to airways. You'd think this is a good thing, resulting in better asthma control (although modern studies can even debate that). However, while true, it also increases the amount of medicine that comes into contact with pulmonary blood vessels. These medicine particles do not participate in first pass metabolism. Instead, a majority, if not all, of these particles directly enter your circulatory system, where they might participate in systemic side effects.

So, while a spacer might improve coordination and reduce side effects, not using a spacer may reduce side effects even more so than using a spacer. This is important, because this is how pharmaceuticals like AstraZeneca prevent side effects from corticosteroids and long-acting beta adrenergic medicines.

Bottom line, the dose of Symbicort is adjusted to account for a lung distribution of only 9%. If it were assumed that 100% of patients used a spacer with Symbicort, then the dose of the medicine would be adjusted downward to compensate for the improved lung distribution. This would be necessary to prevent side effects. So, I know this was a complicated explanation, but might explain why the package insert for Symbicort recommends that no spacer be used.

So, what should you do? Personally, where I work we distribute spacers with all inhaler products. I think this is the way it will be done until the medical profession adjusts to this new wisdom. For legal and ethical purposes, I think following your hospitals policy is the best policy. However, when you are using your own inhaler product, whether you use a spacer is up to you.

References.

“A Guide for Aerosolized Delivery Devices for Respiratory Therapists,” 3rd edition, https://www.aarc.org/education/online-courses/aerosol-devices/, accessed 8/4/17

Irwin, et al., “Side Effects With Inhaled Corticosteroids,” Chest, July, 2006, http://journal.chestnet.org/article/S0012-3692(15)32956-1/pdf, accessed 8/3/17

“Spacers with inhalers: Do they make a difference,” American Academy of Allergy, Asthma, and Immunology, 2017, Jan. 18, https://www.aaaai.org/global/latest-research-summaries/New-Research-from-JACI-In-Practice/spacer-inhaler, accessed 8/5/17

Saag, Kenneth G., et al., “Major Side Effects of Glucocorticosteroids,” 2017, https://www.uptodate.com/contents/major-side-effects-of-inhaled-glucocorticoids, accessed 8/3/17

Barnes, Peter, J., "Inhaled Corticosteroids," Pharmaceuticals (Basal), 2010, March 3, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033967/, accessed 8/1/17

Romme, “Fracture Prevention in COPD: A clinical 5-step approach,” Respiratory Research, 2014, https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-015-0192-8, accessed 6/20/17

BiPAP and CPAP: Answering all your questions

Your question: How high can you set CPAP? What are the disadvantages of CPAP that is too high?

My answer. This is a good question. According to Egans, CPAP is a continuous flow of pressure on inspiration and expiration.If there are alveoli that are collapsed due to atelectasis, CPAP acts to recruit them, and open them up. It thereby acts as a splint to keep them open to improve oxygenation. If CPAP levels are set too high, alveoli will be over-distended, and this may result in air trapping. (1, page 1066)

Another thing to keep in mind here is that CPAP acts to reduce venous return to the heart so the heart doesn't have to work so hard to pump blood through the body. This is the advantage of using CPAP to treat heart failure. If CPAP is set too high, this pressure may ultimately reduce venous return enough as to cause a reduction in cardiac output, which can be measured by a drop in blood pressure.

Over-distended alveoli and air trapping can also result in a drop in oxygen levels, and this can be measured by oxygen saturation monitor.

Your Question. How high can you set IPAP on a BiPAP machine?

My answer. The best answer I can give to this question is a theory, as is much of the medical profession. From what I have read (and you can help me find a source here) is that a pressure support or IPAP higher than 20 in a non-intubated patient may act to obstruct, or block, the esophagus. This can prevent the patient from swallowing. You can exceed a pressure of 20 if you absolutely must to improve oxygenation or ventilation. However, if you must do this, talk to the doctor about ordering a nasal gastric tube (NG). 

While it's generally not a good idea to exceed the recommended settings, I have from time to time had doctors insist I do this. I just make sure to remind the physician that there is a down side to too much pressure.

Your question.  Is it true that you need an IPAP greater than 10 to be therapeutic?

My answer. The goal of IPAP is to assist with inhalation to reduce work of breathing and improve ventilation. If an IPAP of 10 results in an ideal tidal volume for that patient, then an IPAP of 10 will be fine. Some patients have small frames, in which case an IPAP of 10 (or less) may provide adequate support. Keep in mind here that some people with COPD do not have enough lung function, especially during flare-ups, to adequately blow off CO2. For these patients, just assisting them get to their normal, ideal tidal volumes will be all that is needed. So, you do not necessarily have to blast patients with the highest pressure support. If you are getting adequate tidal volumes (using your usual formula of 6- ml/kg ideal body weight), then you are probably fine.

Your question. Is it true you can't set a rate on BiPAP?

My answer. Part of the advantage of BiPAP, is if the machines senses that a patient hasn't taken a breath, it can force the patient to take a breath. This is ideal for preventing sleep apnea. So, ideally, you should set the BiPAP rate at around 6-8. Usually patients will breathe over this set rate. However, if they don't, then the machine will assure at least a minimum respiratory rate.

Your question. How are CPAP and BiPAP set? What are the ideal settings to use?

My answer. The ideal settings should be determined by doing a sleep study. A sleep study technician will titrate settings until the best settings are determined. You will want the lowest setting necessary to keep airways open and maintain adequate oxygenation. Of course, you don't want too high to prevent drops in blood pressure and oxygenation as noted above. There are also newer machines that are auto-titrating.

Your question. When you are setting up a patient on BiPAP in the clinical setting, what are good start settings?

My answer. This is open to debate. It is also open to varying opinions. The general consensus where I work is ideal start-up settings are IPAP 10 and EPAP 4. Settings can be adjusted until an ideal tital volume and oxygenation status is determined.

Your question. How big of a gap between IPAP and EPAP do you need.

My answer. The answer here is another one that is open to personal opinion. The general consensus where I work is that you would like to keep the gap at a minimum of 5. For example, you will want to set the IPAP at least 5 over EPAP. Keep in mind, however, the ventilator that you are using.

Your question. How is Pressure Support (PS) measured on BiPAP. It depends on the machine you are using. On the V60, it is measured over PEEP. So, if you are using a V60 ventilator, and you have the IPAP set at 10 and the EPAP set at 5, you are essentially using a Pressure Support of 10 and a CPAP of 5. On the other hand, if you are using a machine that does not measure PS over PEEP, and you use settings of 10/4, then the measured PS is 5. So, this is why it's important to know your machine.

Your question. Is it true that if a patient requires BiPAP post extubation that the patient never should have been extubated and should be re-intubated?

My answer. Actually, this subject has been extensively studied, and the results are relatively inconclusive. However, some studies show that BiPAP post extubation may prove useful in some patients, especially those with end stage COPD where airway protection and pulmonary toilet is not a concern. This may occur when patients are incorrectly assessed for readiness to wean, or when patients self extubate. It may also occur in some patients, such as those with end stage COPD who are anticipated to still need some support although you don't want to risk further complications of intubation, and a trial of post-extubation BiPAP is done on purpose. Some studies do show this may prove beneficial. However, it should also be noted that the patients described here have a 40% mortality rate.  (5)

Your Question. Does BiPAP really help with heart failure? Doctors say it pushes fluid out of the lungs.

My answer. Both CPAP and BiPAP, by providing increased intrathoracic pressure, have been shown to reduce both cardiac preload and afterload, which reduces the amount of work the heart has to do. Some physicians think it works by pushing fluid out of interstitial spaces, and this is why it works. However, while this does occur to a small extent, it's not enough to have a therapeutic benefit. (5)


Your Question. Does BiPAP truly benefit people with COPD.

My answer. Yes. Studies seem to show that IPAP reduces airway resistance due to bronchospasm and secretions to make it easier to take in a breath and reduce dyspnea The machines can also sense when a patient has not taken a breath to force them to take a breath, thereby preventing apnea. EPAP also acts to splint the upper and lower airways to keep them open at end expiration. This prevents soft tissues in the upper airway from collapsing and causing apnea, and it also recruits collapsed alveoli and keeps them open to improve oxygenation. Various studies have shown that BiPAP used to treat episodes of severe COPD, whether caused by COPD or heart failure, in the hospital setting greatly improves outcomes and hospital length of stays, and reduced hospital costs. Part of this is because BiPAP often prevents the need for invasive intubation and mechanical ventilation. Nocturnal BiPAP used every day at home for a minimum of four hours per day significantly reduces COPD flare-ups and makes them less-severe when they do occur. This has made it so that people living with COPD can live long lives with quality. (1, 4, 6)

References:

1. Kacmarek, Robert M., James K. Stoller, Albert J. Heuer, “Egan’s Fundamentals of Respiratory Care,” 10th edition, 2013, Elsevier Mosby, pages 1066, 1134-5
2. “Non-Invasive Ventilation in COPD Exacerbations,” Nursing Times, September 3, 2013, https://www.nursingtimes.net/clinical-archive/respiratory/non-invasive-ventilation-in-copd-exacerbations/5062992.article
3. Criner, Gerard J., Rodger E. Barnette, Gilbert E. D’Alonzo, editors, “Critical Care Study Guide: Text and Review,” 2nd edition, 2010, Springer
4. Respiratory Therapy Magazine: Noninvasive BiPAP Systems May Help COPD Patients, January 28, 2015, http://www.rtmagazine.com/2015/01/noninvasive-bipap-systems-may-help-copd-patients/, accessed 3/31/17
5. Maclntyre, Neil R., “Mechanical Ventilation: Noninvasive Strategies in the Acute Care Setting,” Medscape, http://www.medscape.org/viewarticle/450209, accessed 3/31/17
6. Ankjærgaard, Kasper Linde , et al., "Home Non Invasive Ventilation (NIV) treatment for COPD patients with a history of NIV-treated exacerbation a randomized, controlled, multi-center study," BMC Pulmonary Medicine, 2016, http://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-016-0184-6, accessed 4/1/17
7. Respiratory Therapy Magazine: Nocturnal BiLevel Ventilation for the COPD patient," February 7, 2007 http://www.rtmagazine.com/2007/02/nocturnal-bilevel-ventilation-for-the-copd-patient/, accessed 4/1/17
8. Lainscak, Mitja, Stefan D. Anker, "Heart failure, chronic obstructive pulmonary disease, and asthma: numbers, facts, and challenges," ESC Heart Failure, volume 2, issue 3, 2015, pages 103-107, http://onlinelibrary.wiley.com/doi/10.1002/ehf2.12055/pdf, accessed 4/2/17

The two types of asthma wheezes

I have written a couple posts explaining how you cannot hear bronchospasm without the aid of a stethoscope. I described it in my post, "The 9 Different Types of Wheezes" and "What albuterol does, and does not do."

Here is your question:

"My 10 year old son has asthma. Sometimes, I can hear him wheeze when he walks in the room. I put my stethoscope on him and hear wheezes throughout. He says it's hard to breathe. He uses his albuterol inhaler and feels better. I can't hear the wheezes anymore. I put my stethoscope back on him and hear improvement. So what am I hearing when I can hear him wheezing without my stethoscope? That wheezing is not his asthmatic bronchospasm?"

Here is my answer.

Great question. I observed the same thing in myself when I was a kid, that I would sometimes audibly wheeze when I was having asthma symptoms. My theory is you can't hear bronchospasm without the aid of a stethoscope. However, asthmatics also produce excessive amounts of mucus from an abnormally high number of goblet cells. This mucus makes it's way to upper airways, causing a wheeze as air moves throu them (it's usually just heard on expiration, although it may be inhalation and exhalation).

As air moves through these airways, an audible wheeze may be heard. I had many nurses tell me when I was a kid that my wheezes were audible, so they can't be bronchospasm. She was right to think that an audible wheeze was not bronchospasm. But what she failed to consider was that you can have both upper airway and lower airway (it's bronchospasm) wheezes at the same time.

Keep in mind this is just my theory. However, I have also been living with this disease, and studying this disease, for over 40 years.

Also keep in mind that both these articles were not meant to imply that albuterol has no place in the treatment of asthma attacks. It was to imply that not all that wheezes is asthma.

Can you set a rate on a BiPAP

 Your Question.  Where I work, we have a doctor who insists on having the backup rate set at 16-20 on patients with high CO2s.  I tried to explain to him that we cannot do this on a BiPAP. Am I right.

My Answer.  You are right.  BiPAP provides a breath to the patient when a certain flow is sensed. If the patient is breathing at a rate of 10, and you put in a rate of 16, the machine is going to continue to try to force in a breath while the patient is exhaling.  All this is going to do is create asynchrony between the machine and patient.  It will create little blips on the waveform that do not result in breaths.  The BiPAP is going to constantly alarm while this is occurring anyway, so you won't be able to do it for long without irritating the patient, nurses, and probably even yourself.

 On the contrary, you can set the backup rate to less than the patient's current rate.  For instance, if the patient has a rate of 16 while he is awake, you can set a backup rate at 8. This way, if the patient is sleeping and has apnea episodes, you can be sure the patient will continue breathing.  This is okay because the patient won't be exhaling against the machine breath.  Obviously you will want the back up rate to be enough to assure adequate ventilation to blow off CO2, although never so high that the BiPAP has a higher rate than the patient's rate when he does start breathing again.  Usually, a back up rate of 6-8 is just fine.  Although, as always, it's important to create settings that are appropriate for a given patient at a given time.

Is Brovana a rescue inhaler?

Your Question:  Is there any evidence of Brovana as a rescue medicine.

My Answer:  Brovana is a Long Acting Beta Agonist that should never be taken more frequently than twice a day.  It helps to keep your airways open long term so you need your rescue medicine less often.  Still, if you get short of breath between doses, you can use your rescue medicine.  Studies show that Brovana starts to open airways within a median time of 6-7 minutes. This means that it can work quicker in some patients.  I usually recommend my patients use their Brovana first if it is close to being due, and, if they continue to feel short of breath after 10-15 minutes, to then use their rescue inhaler.  Usually my patients tell me the Brovana works great toward helping them get their breath back and they do not use their rescue inhaler at that time.  So, Brovana is not a rescue inhaler, but it can still make your breathing easier just like a rescue inhaler.  Please note, however, that Brovana, like all other LABAs, should never be used more frequently than prescribed, which is usually once or twice a day.  

'Should I become an RT?'

I get all sorts of questions from high school students who want to become respiratory therapists.  Among the most common from students here in Michigan over the past year is whether they should pursue the profession in light of efforts to deregulate the profession.

I recently received the following question from a follower of the RT Cave on Facebook.  I do know his name, but for the sake of this post I will keep it anonymous.  He wrote:

Hello, I am hoping that you could help me out. I am worried about my choice too go into respiratory care. Respiratory care is the career I want the most,but I am always reading that respiratory care is going too be deregulated in Michigan, and that I will never find a job after respiratory school. I was wondering if you might look into these things for me since you are actually an respiratory therapist and tell me what you think. I am going too start volunteering in etheir the emergency room or respiratory care department too just learn some things and help my decision on respiratory, nursing or radiology. Hopefully you can give me some honest information and help guide my decision. Thank you:)

I humbly responded:

Don't let that kind of talk sway you one way or another. First of all, such is just talk and more than likely won't succeed. Second, even if it did succeed it would have no effect on our profession. We existed just fine prior to regulation, and since regulation there have been no changes. So, don't worry about it. We need people like you in this profession. So Go for it!

Surely there are flaws with our profession as there is with any other, but whether or not we are regulated or deregulated is not one of them.  The profession makes for a decent career, especially if you love to work with people, and you like to help people "breathe better."

Littman: The best Stethescopes

Your Question: What is the best stethescope to use as an RT?

My humble answer: Good question. I'd go with a Littman. Here is a link to one site that sells them, yet I just chose this one because it has some good pictures with prices. I have a Littman cardiology III which costs about $120 and has a five year warranty. I purchased this one because it has both an adult and a pediatric head that I need because I take care of both populations.

However, any one that fits your budget will work fine. I've used them all at some point.

You have to keep in mind here that your specialty is lung sounds, and therefore you will want to have a stethescope that will allow you to hear all lungsounds. You certainly don't want to have a cheap $10 stethescope that someone else purchased at a dime or dollar store, or your local pharmacy (like the light blue one pictured below).

Another neat things about lung sounds is they help you to pre-diagnose. If you miss those fine crackles in the bases, you might get the wrong initial impression of the patient. Plus picking up on certain lung sounds with a good stethescope will allow you to be proactive.

As you start working in a hospital you'll see many nurses carrying around a cheap stethescope like the one in the picture to the right. If you see one of those, you're seeing a nurse or an RT who doesn't value hearing all lung sounds, because you won't be able to.

What I find funny is when I'm watching a show like Becker or ER and seeing well paid doctors with cheap stethoscopes. Any astute physician can easily afford a good stethoscope.  So the fact the cheap ones are often seen on TV doctors shows the naivety of Hollywood.

That's why they should hire me and pay me a million to watch movies and TV shows to make sure all the medical stuff is right.

Anyway, I know college itself can get kind of expensive, but it's especially important you get a good stethoscope before you go to your first clinical. I'll give you two more good reasons.

1. Your preceptor will probably want to show you how to listen to lung sounds. When this happens, you'll want to make sure you're hearing what your preceptor is hearing. A good stethescope will allow you to do just that.
2. A cheap stethescope makes you look like a cheap RT or RN, as opposed to the elite one that you are. Don't sell your self short, be the best, and have good ears.

And no this is not an advertisement for Littman.  There are probably other good stethoscopes out there, but Littman seems to have a good grasp on the market and have me brainwashed.

This post was originally published on August 7, 2010, right here on RT Cave.  It has since been edited. 

Further reading:

• Lungsound lexicon
• How to listen to lungsounds
• How to hear bronchospasm

Why is a normal SpO2 98%?

Question:  Why is a normal oxygen saturation 98% and not 100%?

Answer:  After the diffusion of oxygen from the alveoli to the capillary occurs, this oxygenated blood moves to the pulmonary vein to the left atrium.  This blood contains a PaO2 of 104, on average.  This blood constitutes 98% of cardiac output.  Another 2% of the cardiac output comes from the bronchial veins, and this blood has a PaO2 of 40.  This unoxygenated blood is shunted into the pulmonary vein, and mixes with arterial blood.  It is because of this natural shunt that a normal saturation is 98% and not 100%.