Studies conclude: Atrovent can't hurt

There does appear to be evidence that supports the theory that giving ipatropium bromide (Atrovent) for the treatment of asthma and COPD flare-ups in the emergency setting may be beneficial.

According to Aaron SD et al in 2001, the following results were discovered:

• Data from 10 studies of adult asthmatics, reporting on a total of 1377 patients, were pooled in a meta-analysis using a weighted-average method. Use of nebulized ipratropium/beta2-agonist combination therapy was associated with a pooled 7.3% improvement in forced expiratory volume in 1 sec and a 22.1% improvement in peak expiratory flow compared with patients who received beta2-agonist without ipratropium. 
• Similarly, randomized controlled studies of pediatric asthma exacerbation and a meta-analysis of pediatric asthma patients suggest that ipratropium added to beta2-agonists improves lung function and also decreases hospitalization rates, especially among children with severe exacerbations of asthma. 
• The adult and pediatric studies did not report any severe adverse effects attributable to ipratropium when it was used in conjunction with beta2-agonists.
• In conclusion, there is a modest statistical improvement in airflow obstruction when ipratropium is used as an adjunctive to beta2-agonists for the treatment of acute asthma exacerbation. In pediatric asthma exacerbation, use of ipratropium also appears to improve clinical outcomes; however, this has not been definitively established in adults. It would seem reasonable to recommend the use of combination ipratropium/beta2-agonist therapy in acute asthmatic exacerbation, since the addition of ipratropium seems to provide physiological evidence of benefit without risk of adverse effects. (1)

In a comparison of Ventolin given without Atrovent and Ventolin given with Atrovent, Watanasomsiri A1, Phipatanakul W. concluded:

Of 74 children randomized and enrolled in the trial, 71 had complete data for analysis. Thirty-three children were in the control group and 38 were in the treatment group. Both the percent change in PEFR and the change in percent predicted PEFR at any time were higher in the treatment group, but these findings were not statistically significantly different. The number of subjects with at least a 100% percent predicted PEFR at any time point was greater in the treatment group. (2)

They concluded:

Although this study did not demonstrate a significant advantage in clinical score and PEFR, the trend toward additional effect of ipratropium bromide was consistent with previous studies. (2)

In comparing treatments with ipatropium bromide alone, or albuterol alone, or both together, Ward et al concluded:

The two drugs in sequence produced greater bronchodilatation than either used alone, and the mean peak expiratory flow rate rose by 96% in four hours. Thus giving ipratropium bromide in addition to salbutamol in severe asthma enhances the bronchodilator effect. (3)

The bottom line here is that, while there is no conclusive evidence atrovent will help with acute exacerbations of asthma, side effects are negligible.  That seems to be the mantra for using most respiratory medications: it can't hurt.

Both medicines have received an expanded role, for not only are they prescribed together (usually in the form of Duoneb) for asthma patients, they are prescribed together for nearly all lung ailments, including those not proven to benefit from this type of therapy.

There are some physicians who will allow the respiratory therapist to limit the frequency of atrovent to every four hours.  However, there are many physicians who order Duoneb even for continuous breathing treatments.

So what are your thoughts?

References:

1. Aaron, SD, "The use of ipratropium bromide for the management of acute asthma exacerbation in adults and children: a systematic review," Journal of Asthma, October, 2001, 38 (7), pages 521-530, accessed on 5/18/14 http://www.ncbi.nlm.nih.gov/pubmed/11714074
2. Watanasomsiri A1, Phipatanakul W., "Comparison of nebulized ipratropium bromide with salbutamol vs salbutamol alone in acute asthma exacerbation in children," Anal of Allergy, Asthma and Immunology, May, 2006, 96 (5), pages 701-706, accessed 5/18/14, http://www.ncbi.nlm.nih.gov/pubmed/16729783
3. Ward, M.J., P.H. Fentem, W.H. Smith, and D. Davies, "Ipatropium Bromide in Acute Asthma," British Medical Journal, Feb. 21, 1981, 282 (6264), pages 598-600, accessed 5/18/14, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1504444/

What's the difference between Albuterol and Atrovent?

Every day at MyAsthmaCentral.com we get lots of asthma related questions. Below are some questions I thought my readers at the RT Cave would enjoy.

Question: What is the difference between Ventolin and Atrovent? I have been getting jittery when using Advair, Prednisone, Theophylline and Ventolin, and my doctor says Atrovent may help instead of Ventolin

My humble answer: With all those meds, it sounds like you have hardluck asthma.

The problem is, every one of those medicines you're on can cause the jitters. That's the thing with asthma is you have to balance the advantages of taking asthma meds with the disadvantages. And sometimes we asthmatics, while we're trying to get our asthma under control, have to put up with side effects -- mainly the jitters.

The thing about Ventolin, as I'm sure you know, is it gives you immediate relief you can feel, and that's why it's called a rescue medicine. Atrovent can open your airways too, but its effects are generally mild and may take longer than Ventolin. While Atrovent is generally not recommended by the asthma guidelines as a frontline medicine for most asthmatics, it has proven beneficial for some. So you should try it and see if it works for you. But Keep your Ventolin on hand just in case you need it.

Here's some information about Ventolin and Atrovent:

Ventolin is a beta adrenergic medicine. It is a medicine that attaches to beta 2 receptors that are on the muscles that surround the air passages in your lungs (bronchioles) and cause the air passages to relax. It can rapidly open up your lungs making it easier to breathe. It is considered a front line medicine for treating acute asthma symptoms.

Atrovent is an anticholinergic medicine. Our bodies release a natural neurotransmitter (Acetylcholine) that attaches to cholinergic receptors in the muscles surrounding the air passages in our lungs. This cause these muscles to spasm, and your air passages to become narrow (bronchoconstriction). Thus, Atrovent particles attach to these cholinergic receptor sites and block the cholinergic response, thus prevening this airway narrowing. To control asthma, usually there are better medicines than this. However, when all else fails, this is a good option to try. Most experts call Atrovent a back door bronchodilator.

I hope this information helps. Good luck.

If you have any further questions email me, or Visit MyAsthmaCentral.com's" Q&A section.

Atrovent Happy doc may be on to something

We have a doctor here at Shoreline who orders Atrovent on every person who is ordered up on a treatment. The idea is, if you require a treatment, you get Atrovent. In fact, if you require a continuous Albuterol, you also require continuous Atrovent.

When she's working, I stock up on Duoneb. And yes, she also gives it to kids.

When she started working here I questioned her excessive Atrovent orders, but she's the kind of doctor who knows what she wants and orders it regardless of what you think.

In fact, in RT school back in 1995, we learned that Atrovent should never be given more often than every four hours.

I've often wondered what she has read that has her so up on Atrovent. One study I found was that Atrovent can benefit asthmatics, even those having acute symptoms. But that was just one study.

Another study showed that Atrovent given in conjunction with Albuterol resulted in more patients improving in the emergency room and being discharged, compared with those just given Albuterol.

So, perhaps Dr. Atrovent knows what's she's ordering.

When I was a kid I used to take Atropine for my asthma. Back then it was common to use it for asthma. In fact, when I was first put on it by my doctor at National Jewish in Denver when I was a patient there in 1985, I was told it was a preventative medicine more so than a rescue medicine, which is basically true even as it is used today.

Then I was put on Atrovent when it came out because the side effects were less. Then I was taken off the medicine altogether because it was no longer recommended for asthma.

However, anticholinergics have long been recommended for COPD. In fact, the newest anticholinergic used is Spiriva, which has been proven (via tests) to actually improve lung function in such patients.

Yet, according to Allergy and Asthma: Practical Diagnosis and Management, "A subset of asthma patients may respond favorably to inhaled... anticholinergics such as (Atropine and now Spiriva). Although this class of medications alone is not considered sufficient as therapy in asthmatic patients, it may be a useful adjunct in some patients."

Then the author adds this, which is why I wrote this post: "There is limited experimental evidence in animal models that this class of medications may potentially limit airway remodeling, thus potentially expanding the future role of these drugs in asthma. However, at present there is not enough evidence to make such a recommendation."

Perhaps, in some asthma cases, Atrovent or Spiriva might prove beneficial. Perhaps our ER doc who is Atrovent happy is on to something. And besides, even if the Atrovent doesn't result in immediate results, there are basically no side effects so what can it hurt to try.

My answers to your RT queries

Every week I check my statcounter to see who's typing things into Google or Yahoo and being linked to my RT Cave blog. Assuming the queries were not answered, I provide in this spot each week my humble responses.

And, hey, if the query is comical, it deserves a comical response. If it's serious, I treat it as serious. That in mind, here are this weeks queries:

1. career change respiratory therapist to rn : While I think that RT is a noble profession just like RN, we RTs are still working on developing the same kind of respect RNs have in the medical profession. We have made major strides just in the 10 years I've been an RT. But we have much farther to go. That in mind, there are some struggles in the RT community. Likewise, pay is not as great as for RNs. Fair? Well, if you don't think so, you can always become an RN yourself. Still, can you go from a mucus sucker, frivolous Scrubblin-Bubblin giver, roamer of the entire hospital to a poop scooper person who has to take care of the same patient all night. For the advantages and disadvantages of being an RT, click here.

2. how to break up wet lungs: Despite the myth that aerosolized sulfate will bind to the fluid particles in the lungs forcing the body to "exhale" the fluid, this IS -- my friends -- just a myth. Actually, if you have a patient with wet lungs, a diuretic is the best method of getting fluid from the lungs to the Kidneys and out of the body through the urinary tract. For more information about diuretics, click here. If by "break up" you are referring to pneumonia, the only thing that will "break up" pneumonia is the human body's defense system, and sometimes with a little assistance of an antibiotic.

3. what is the indication for albuterol with atrovent? It's basically the preference of the doctor. Some studies do indicate slight improvements when Atrovent is used in conjunction with Albuterol in emergency rooms. Others show that it works well for COPD to improve lung function long term (click here for more). Most studies show Atrovent is not beneficial for asthma patients. Whether they want to believe every study that's out there is up to the discretion of each individual doctor. Out of the hospital Atrovent is no longer used as a rescue bronchodilator. It is used as a "preventative" asthma medication. For more information about Atrovent as a bronchodilator click here and here.

4. coarse lung sounds: There is no such thing as coarse lung sounds. If you are hearing coarse, then what you are really hearing is rhonchi. Click here for more information.

5. dont give incentive spirometer to copd patietns: This is a fallacy. There is no reason a COPD patient couldn't benefit from good old fashioned deep breath with a breath hold followed by a cough. In fact, I would recommend it.

6. will unprescribed ventolin hurt children? Not any more than prescribed Ventolin, unless it was obtained by some illegal source; or unless it is outdated. Still, if you decide to use some other person's prescription, you should at the very least call your or your child's doctor.

7. baby's chest caves in while crying: This could be a sign of respiratory distress. Click here and check the other signs of respiratory distress.

8. atrovent pulmonary oedema: I have not seen any studies that show Atrovent does anything for pulmonary edema. If you find any studies to the contrary I would love to read about it.

9. when to stop singulair for asthmatics: Of course I'm no doctor, but I think the general consensus is you do not ever stop taking medications that are preventative in nature unless some better and safer med comes along, OR if you experience side effects that effect your quality of life. Singulair is a medication that works to prevent you from responding to your allergens, and there fore if you stop taking it you could have trouble with allergies and asthma. Asthma medicine should never be stopped without the explicit direction of a physician.

10. dummies guide to respiratory care: Sometimes that's how I think of this blog. However, none of my readers are dummies. You are all brilliant.

Monday's class: My response to your queries

This post is my weekly attempt to answer Internet search engine queries that lead someone to clicking onto my medblog.

We determined last week that 62% of people who click onto this blog stay here long enough to determine it's not where they want to be. Likewise, we also determined that if they would have stuck around a bit, they may have found the answer they were looking for.

Of the 500 queries in my stat counter's memory, I have picked ten of the most interesting queries. Keep in mind I do not answer queries if the page the person landed on would have provided them with an appropriate answer.

Here we go:

1. Frequency of Duonebs: Duoneb is a combination of Atrovent and Albuterol, and ideally it should taken no more often than every four hours. If you need to use it more often you should see your doctor. This medicine can be safe if used more often, but should not be done without the approval of a doctor.
2. am i smart enough to be respiratory therapist: When I first researched the career of RT I found out I had to take chemistry, and I failed chemistry in high school. Based on this, I decided RT school would be too hard for me. I could not have been more wrong. If I'm smart enough to be an RT, you are too.
3. respiratory therapy is not a good career: That kind of depends on how you define a good career. If you want to get rich and buy a bunch of material items, then this is not the career for you. Like any job, there are ups and downs of being an RT. It is what you make of it.
4. xoponex q2: It's safe. However, I would not recommend this frequency outside the hospital setting.
5. albuterol pulmonary edema: Albuterol has absolutely no effect on Pulmonary Edema. Albuterol relaxes the bronchioles, and pulmonary edema occurson the outside of the bronchioles. For more information see #9 below.
6. do respiratory therapists use stethoscopes: Absolutely. If you see one who doesn't you ought to report him or her and wonder if you are receiving good care.
7. what happens to fio2 when using a simple mask and the patient breathes deep: The simple mask is a low flow oxygen device, meaning that the FiO2 is dependent on the patients respiratory rate and tidal volume (minute ventilation).
8. i hate my job, respiratory therapy: It's a free country. Nobody is stopping you from getting a different job. Go for it.
9. does wheezing mean you have copd: Not always. If the muscles of the bronchioles are spasming, this will cause a wheeze. This is called brnchospasm and occurs with COPD or asthma. Albuterol can relax these muscles almost instantly, making it much easier to breathe. Pulmonary edema occurs as a result of the heart pooping out, and fluid backs up and fills the lungs. This can be caused by Chronic Heart Failure (CHF). If the pressure in the lungs gets high enough with CHF, this fluid in the lungs will actually squeeze the bronchioles, causing a wheeze. Because this is caused because of a weekend heart, it is called a cardiac wheeze. Sometimes, however, it is hard to tell the difference.
10. Bipap asthma: I've actually seen it work well for some asthmatics, however when an asthmatic is really short of breath he may actually feel claustrophobic enough without the BiPAP. Thus, if the patient can tolerate it, go for it. BiPaP should always be ordered to tolerance.
11. continuous aerosol with atrovent: I questioned it too, but some doctors where I work have done it with no consequences. Atrovent is similar to Albuterol in that the side effects are minimal. If Albuterol is safe, Atrovent is even safer. Some recent studies show some added benefits to COPD and Asthma patient with giving continuous Atrovent along with continuous Albuterol. As with everything in the medical field, every doctor or RT will have a different opinion on this. With that in mind, I do not see any point in giving a continuous treatment with just Atrovent. If a patient is so short of breath he or she needs a continuous treatment, then you better throw in some Albuterol. (Note: a continuous treatment is when you give a treatment back to back to back until the patient starts to open up.)

Keep in mind I receive hundreds of queries a week, and I am limited in space on this weekly column.

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact us at Freadom1776@yahoo.com, or RTcave@yahoo.com.

That concludes today's class.

Rescue bronchodilators: Here are my unfettered answers to all of your questions about them

The following are some questions real patients have asked me recently regarding rescue bronchodilators. The answers here are my humble personal and professional opinions and nothing more.

Keep in mind that your doctor might disagree with me, and that's fine. He can overrule me whenever he wants. But, the answers here are based not just on my 10 years as an RT, but over 30 years as a chronic asthmatic who's abused more than his share of inhalers and lived to tell about it.

Q) What is the recommended dose for albuterol

A) Every 4-6 hours as needed ( no surprise here.)

Q) What if I need it more often than that

A) For most patients, I'd recommend seeing your doctor if you need it more often than every 4-6 hours, because it's a sign that your asthma or COPD is getting worse and needs to be better controlled. However, it's a relatively safe medicine, and some doctors prescribe it to be used as needed for some chronic patients.

Q) What do you think of a doctor ordering Albuterol MDI every four hours?

A) Albuterol is typically a rescue medicine, and should be taken when you are short-of-breath (SOB) due to bronchospasm. It's not going to hurt if you use it more often than when you need it, but I don't see why it would be beneficial.

Q) My doctor says Albuterol will work to prevent an asthma attack, so I should use it every four hours all day. Is this true?

A) I was taught when I was kid to take my Albuterol before I took gym class, and I did. However, it never prevented me from getting SOB. It did, however, make me feel better once I was SOB. So to answer this from my own personal experience, I'd have to say no; Albuterol does not prevent asthma symptoms. However, you can try it to see if it works for you.

There are many doctors who do believe it can be used as a preventative drug. Not only that, it states this on the Albuterol package insert. However, if it is deemed necessary that preventative medicines be taken to prevent an asthma attack, there are far more effective medicines to be using, such as Vanceril, Flovent, Atrovent, Cromolyn, Advair, etc. (this will be discussed in a later post.)

Q. I've had an Albuterol inhaler for the past 3 years. Sometimes I use it more that 10 times in a day, which is more than the prescribed frequency of every 4-6 hours. Can I use Albuterol this much and feel safe?

A. I'm treading on thin water here, but I will say yes. I find from my own personal experience as a former Albuterol abuser, and professional experience giving treatments, that Albuterol is a very safe medicine. The most common side effect is that it might make you jittery, which you probably already know if you've done it before. If you were going to have a negative reaction to the medicine, like an increase in heart rate, it would have happened already.

However, if you have other medical issues besides just COPD or Asthma, then I'd be really cautious of using too much Ventolin. I'd recommend consulting your doctor if you need to do this. Personally, though, I still think Albuterol is safe and effective in most situations where real bronchospasm is the issue.

Q. But my doctor has me on all the right preventative medicines and I'm still finding myself going through an inhaler a week. Will this have long term implicaitons on my life span?

A. I asked my doctor that exact question when I was a kid, and he told me using my inhaler was better than suffering and chancing an anoxic episode. If you absolutely have no choice than to use your inhaler more than every 4-6 hours, make sure your doctor knows about this. Chances are, he will still renew your prescription because he doesn't want you to suffer. However, he may also continue to try to adjust your other medicines to make your life easier. Sometimes, however, as in some cases of COPD or end stage COPD, this is not possible.

Let me answer this question this way. I went through an inhaler a week from the time I was 13 or 14 until about a year ago when I started taking Advair. That was 25 years. I'm getting along just fine now. Will my Albuterol abuse cut some years off the end of my life? Well, nobody really knows. Albuterol has only been around since 1987. Personally, I doubt it will.

Q. My doctor prescribed Atrovent as my rescue inhaler, what do you think of that? Should I be worried if I use it more than four times a day, because I do?

A. Atrovent is not a rescue inhaler. Atrovent takes about 20-30 minutes to work, while Albuterol, idealy, should work almost instantaneously for bronchospasm. Then again, if Atrovent works for you, then that's great. If it isn't, then I'd talk to your doctor about getting an Albuterol inhaler.

Q. Am I safe using Atrovent more often than every four hours, because I do?

A. I don't see what it would hurt. When I was in school ten years ago we were taught never to use Atrovent more often than Q4. However, some new research shows that addtitional Atrovent during an exacerbation does benefit patients. If Atrovent is working for you as a rescue drug, all the power to you. However, if you continue to be short-of-breath, you should talk to your doctor about getting an Albuterol inhaler or (ideally) adjusting your preventative medications.

Q. Can I use my Combivent more than every 4 hours?

A. Again, I don't think it would hurt you, but it's not necessary. Technically speaking, the Atrovent in this medicine shouldn't need to be taken more than every four hours. If you need to use Combivent more than every four hours, then you should talk to your doctor and get an Albuterol inhaler. You can then use your Combivent four times a day, and Albuterol in between if you get short-of-breath. (and still I'd only recommend this only if other preventative medicines weren't working.)

Q. Do you think Xoponex is better than Albuterol?

A. No. I have never noticed a difference. Original studies claimed that Xoponex was stronger than Albuterol, but I've never noticed that to be true in my real life experiences with the two drugs. Not only that, I don't think the claim that Xoponex has fewer side effects than Albuterol is true either. Recent studies have confirmed this.

However, if you have experienced cardiac side effects, or excess jitteriness or nervousness, then you might be a candidate for a trial of Xoponex, if you want to flip the bill: Xoponex costs 5-10 times more than Albuterol.

Q. What if I go through an inhaler a week?

A. Every patient is different. Do you have end stage COPD? If so, you have to do what you need to do. Do you have asthma? Then perhaps you could trial Advair. Advair worked like a miracle drug for me. I went from one inhaler a week and 600mg of theophylin twice a day down to two 300mg pills a week and 4 puffs of Albuterol a day after being on Advair 9 months.

You and your doctor have to find what works best for you. If there is no other alternative, then an inhaler a week might be the best solution.

I meet albuterol abusers at work all the time, and the majority of them are end-stage COPD patients. However, on occasion, I have met a fellow asthmatic who abuses too. Most of them think they are the only one. And, most of them think they are doing this furtively without their doctor's knowing.

Many times I walk into a patients room to give a breathing treatment and find that MDI hidden under the pillow, a sign of a true rescue inhaler abuser.

The latest research on Atrovent

As I wrote last night, we have a doctor here at Shoreline who loves to order Atrovent. Even if a patient needs a continuous treatment, it will be Duoneb, Duoneb, Duoneb, Duoneb and Duoneb. And then an hour later it will be Duoneb again.

I graduated from respiratory school in 1997, and was taught that Atrovent should ideally be given QID but never more frequently than Q4. I don't see what it would hurt to give the drug more often than that, but I also wasn't taught that it had any added benefit either.

But now we have Dr. Krane ordering it galore. She even orders Duoneb on pediatrics and Neonates. Umm, I was under the understanding that it was a drug for COPD patients mostly, or at least just adults. National Jewish Medical and Research Center verifies this.

However, I suppose I could be behind the times in my research. And, as I also wrote yesterday, so too are the other doctors behind on their research, because they still follow the old Atrovent routine.

There is one exception, though, and that would be Dr. Kipper on the floor. He's a new Internist who likes to order Q4 Atrovent treatments. My thinking about this is: why not just go with the inhaler.

So, do these doctors know something I don't? If you guys have any research on this, I'd really appreciate it. I've asked RT students that mosey through here and none of them have heard of anything. I figured if anyone would be up on the latest research it would be the RT teachers.

I did manage to find one article on the Internet "Evidence-Based Medicine for Student Health Services" by Dr. Robert J. Flaherty, MD, of Montana State University, which reports:

The addition of a single inhalation of anticholinergics (such as Ipratropium bromide) to a beta2-agonist regimen may improve lung function in children and adults with acute exacerbations of asthma treated in the emergency department. Multiple-dose anticholinergics improve lung function and may avoid hospitalisation in severe exacerbations.

Dr. Flaherty also lists some studies.

I found a second website which states the same: "(Anticholonergic) can be useful adjunct to beta-agonist in exacerbations for both adults and children-- NHLBI guidelines recommend considering in severe exacerbations." He lists several studies.

Another study from the University of Michigan that states Atrovent works on acute asthma exacerbations in children.

So, based on these reports, the excessive use of Atrovent may benefit Asthma patients, but this still doesn't get to the bottom of every treatment including Atrovent as Dr. Krane does.

Now I have absolutely no problem with giving Duoneb more often than Q4. But, if Atrovent is something that will benefit every person in need of a neb, then I want the other docs to know about this too.

Either way, if these studies are credible, then Atrovent should be given to Asthmatics, and multiple Duoneb treatments do work. If this is true, Dr. Krane appears to be up to date on her research.

If you guys know something I don't, let me know. Sometimes we can be behind the times here at Shoreline, and it's my job to catch us up.

I violated RT Cave Rule #3 and now I must pay

RT Cave Rule #3: If you are trying to get a protocol passed, you have to keep your mouth shut about treatments not being indicated. You must be diplomatic.

I think I got Dr. Krane our ER doctor mad at me tonight. And I suppose that's not good news considering she's the main obstacle to us getting an ER protocol

Dr. Krane was back in her cubby behind the ER desk, and one of the ER nurses said, "So, other than us nobody is bothering you tonight, hey."

"Pretty much you're it," I said, "Except for this one professional COPD patient who calls me every 3 or 4 hours for a treatment."

"Oh, that's pretty good then."

"Yep, He's a pro. I don't even really need to check in on him, he just calls me when he's ready for one."

"That's cool."

"Yep," I said, "And those are the kind of patients that I really like to give treatments to. You know, patients that are really having bronchospasms and need them, as opposed to... just because."

Dr. Krane walked out of her cubby and past me without as much as a look my way. She went to ER Room 1 where I was currently giving the 10th treatment to a patient who came in with a cough and was never short-of-breath.

I followed her into the room, "So, you think you got her cured yet."

Dr. Krane gave me a smile. I'm not sure if that smile was her acknowledging my humor, or her annoyance at my comments. Or if I was just imagining things, because maybe she never heard me in the first place.

However frivolous I think some of the therapies we do are, like this current series of treatments, I rarely say anything to the nurses or doctors about it. I save comment for this blog and make humor of it. I think that'a far better therapy than complaining.

When I'm tired, or have too much time on my hands like tonight, my tounge sometimes slips,
and they give me this look like, "Um, you're trying to get out of work. You're just saying that because you're lazy."

I'm serious. It happens every time I mention something like one of my 'olins, or if I tell them my true opinion of a treatment I'm doing.

---

The first treatment on this patient was Duoneb X2 and then again in an hour.

"Are you short of breath?"

"No."

"Do you have asthma?"

"No."

"Have you ever gotten short of breath?"

"Only when I go into a coughing jag, of which I've had many tonight."

"But you're not short of breath now."

"No."

The patient appears to be in no respiratory distress, and before and after every treatment she has denied short of breath, even after several Duoneb treatments and one Xoponex the wonder drug.

I think DR. Krane is privy to knowledge esoteric to even the other doctors here, because she not only orders Atrovent with every treatment, she will know that someone will be short of breath an hour later.

To me, it would make more sense to have me come back and assess for the need. Then again, if that were the case, I probably would have done maybe one, and the nurses would complain that I was just being lazy.

Okay, so there goes our ER protocol.

I need to be more political. I need to be more diplomatic. I need to keep my mouth shut.

---

I know there is new research on Atrovent. I'm going to try and tackle this in the next few days. I might even talk to Dr. Krane about it; that is, if she still likes me.

If she follows RT Cave Rule #2 we'll be just fine, although, as we RTs so well learn, Drs don't always follow the rules.

RT Cave Rule #4: Hospital workers, especially one's that work nights, do not hold grudges.You can't hold coworkers accountable for what they say under stress, pressure or lack of sleep -- especially lack of sleep.