Prehospital Ultrasounds May Help Diagnose Respiratory Distress

About 90% of breathing treatments ordered in the emergency room are for patients ultimately diagnosed with heart failure. This is according to a non-scientific poll of respiratory therapists

This certainly bodes well for job security, but such injudicious use of Ventolin has also been implicated in respiratory therapy apathy syndrome. It also results in a needless hospital expense, as bronchodilators do not suck fluid out of lungs and do not benefit patients with pulmonary edema and heart failure.

I always thought it would be nice if there was a test to determine who was actually experiencing bronchospasm and who was not. Apparently, researchers have been experimenting with using ultrasounds to find the true cause of respiratory distress, or to differentiate between COPD and cardiogenic pulmonary edema.

Rather than just using a stethoscope, which has its limits as a diagnostic tool, researchers developed a ultrasound protocol that takes less than three minutes to perform. In fact, it can be performed by paramedics in the prehospital setting so that an appropriate diagnosis can be made and appropriate treatment started. 

Researchers say that paramedics, using traditional methods, were accurate in their initial diagnosis only 23% of the time. However, once the ultrasound protocol was adapted, they were accurate 90% of the time. If this is true, then it's something that should be adapted sooner rather than later. 

Further reading and references:

• RT Magazine: Diagnosing respiratory distress via ultrasound
• EMS World: Using Ultrasound For Respiratory Distress

Waste in healthcare

Becker's Hospital Review has a nice little write up called the 8 Types of Waste in Healthcare.  I think the article is great.  I have posted the article below, and I have added my own comments in red.

The term "waste" encompasses an array of definitions for hospitals and health systems, including wasted time, finances, steps and human potential, to name a few.  The profession of respiratory therapy is a perfect example of wasted potential.  Studies have proven that about 80% of the procedures performed by respiratory therapists is either a waste of time or delays time.  

Here are eight types of waste in healthcare, as defined by Mark Graban in his book Lean Hospitals, and shared in Ernst & Young's Health Care Industry Report 2013.

1. Defects. This includes all time spent doing something incorrectly and inspecting or fixing errors. One example of defect waste is the time spent looking for an item missing from a surgical case cart. In the 30 years I've been in the profession I can attest that administrators are more concerned with that you charted as compared with that you helped a patient. 

2. Over-production. This includes doing more than what is needed by the patient or doing it sooner than needed. A broad example of this is the performance of unnecessary diagnostic procedures.  An even better example is EKGs.  Since it's so easy to do, EKGs are a part of nearly every order set in the hospital.  Most EKGs that are ordered are merely to make sure a doctor (or hospital) covers his bases to make sure he doesn't get sued or to make sure the hospital gets reimbursed. Most EKGs are a complete waste of time.  

3. Transportation. Unnecessarily moving patients, specimens or materials throughout a system is wasteful. This type of waste is evident when the hospital has a poor layout, such as a catheter lab located a long distance from the emergency department.  Most RT departments are located in whatever space is left over after every other department is settled.  Most RT departments are stuffed in basements, old closets, or even old shacks on the other side of a river across the street from the hospital.  

4. Waiting. Waiting for the next event to occur or the next work activity can eat up time and resources. Patients waiting for an appointment is a sign of waste, as is employees waiting because their workloads are not level. If I had a dime for every stat EKG I've been called to do only to have to wait 10 minutes for the nurse to put in an IV, or a catheter, or to check a rectal temp, I'd have retired twenty years ago.  
5. Inventory. Hospitals create waste when they incur excess inventory costs, storage and movement costs, spoilage and waste. One example is letting supplies expire and then disposing of them, including out-of-date medications.  Respiratory therapy departments are notorious for wasting medical supplies.  Probably about half of the endotracheal tubes in RT storage bins are yellow.  This is, however, not necessarily the fault of anyone in particular.  It's just one of the things that must occur when you have to be prepared for every occasion. 

6. Motion. Do employees move from room to room, floor to floor and building to building more than necessary? That accounts for one type of waste. Lab employees may walk miles per day due to a poor hospital layout, for example.  Studies show that respiratory therapists walk an average of 20 miles a day.  The main reason for this is to perform procedures that are a waste of time or delay time.  So for those of you who say these wasteful therapies make money for the hospital and keep us at work, they also result in lots of wasteful steps.  

7. Over-processing. This describes work performed that is not valued by the patient or caused by definitions of quality that aren't aligned with patient needs. One example is extra data stamps put onto forms, but that data never being used. This is over my head and between my legs. 

8. Human potential. This waste is caused when employees are not engaged, heard or supported. Employees may feel burnt out and cease sharing ideas for improvement.  Most respiratory therapists develop some type of apathy and burnout due to the fact that our talents and knowledge are rarely utilized.  I have had doctors order breathing treatments for a wheeze, even though the RT has notified the doctor that it wasn't a wheeze but a larygospasm, or cardiac wheeze, or otherwise not bronchospasm.  I have had doctors order BiPAP to offset the pressure from a bloated stomach, or to too tick a patient off and increase his blood pressure.  I kid you not.  It is no wonder so many RTs develop apathy, or as Mr. Frea says, RATS. 

With all due respect, however, it's pretty much like this in any profession whereby you work with people.  Apathy is pretty much something that sets in regardless of your profession, and this should not be a reason to avoid the respiratory therapy profession.  We're just having fun here on this site. 

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Off label use of beta adrenergic medicine

This isn't really said much, but albuterol is only approved by the Food and Drug Administration (FDA) for the treatment of asthma and the prophylaxis of exercise induced asthma.  

However, it's often used off label for many other things, some of which I will list here: 

• Bronchospasm as a complication of anesthesia
• Chronic obstructive pulmonary disease (COPD
• Cough cough
• Hyperkalemia
• Pulmonary emphysema
• Respiratory distress in a premature newborn
• Adjunct to respiratory treatment of syncytial viral infection. 
• LEV is approved for use in asthma and is also used off-label in patients with COPD.

Levalbuterol is only approved for the treatment of asthma, but is often used for COPD.  

While the FDA does not recommend the off label use of any medicine it approves, it is not illegal.  This is a good thing in that it allows physicians the opportunity to be creative in treating their patients, and this does work to the advantage of the patient in many cases.  

However, there are many instances in the hospital setting where both albuterol and levalbuterol are misused and abused. You can see some more examples here at the RT Cave here and here and here. 

References: 

1. Borkowski Jaime, Marsha Crader, "Nebulized albuterol versus levalbuterol in pediatric and adult patients: A review," Formulary Journal of Modern Medicine, April 1, 2009, http://formularyjournal.modernmedicine.com/formulary-journal/news/clinical/clinical-pharmacology/nebulized-albuterol-versus-levalbuterol-pediat, accessed 1/28/2014

Is the false hope worth $120 a pop?

Your question: #1: do no harm. I can't speak for all rts, but most of my pts improve with the therapy given. Some pts despite all efforts whether mythical or not do not. I've never killed anyone with an albuterol. Sure, some docs think it cures everything, but it can make people feel better even if its just in their head. Now lets talk nurses overmedicating and rts having to fix their mistakes. Thoughts?

My answer: Actually it is a fallacy that ventolin causes no harm. We must not for get the s-isomer, which has been proven to cause inert bronchspasm. The more you take the medicine, the more you need it. It's an endless cycle.

I do see your point though. Patients do get the psychological benefit of thinking we're doing something, and the company of an RT.

Yet this has been a problem that has plagued the entire history of medicine, is that most medicine has no benefit other than psychological. Ventolin, like charms, amulets, prayers, and incantations of the primitive world, provides nothing more than the best remedy of all time: HOPE.

In other words, there are times when Ventolin has a real scientific benefit to the patients who receive it. The other 90% of patients receive nothing more than mythical benefits.

Does this "mythical benefit" and "false hope" justify the $120 it costs insurance companies for every treatment given?

Think of it this way, you give a treatment that's not needed every four hours, that's $720 a day, and $5,040 in a week. Is that price worth hope? Of course then you add all the prn treatments given in between because the patient got dyspneic on exertion to the commode, or developed an annoying wheeze, and the price only goes up even more.

Also, taking up a respiratory therapist's time giving a treatment that's not needed takes away time from someone who does need attention. This is a principle concept discussed often in economics 101 courses. It reminds me of the Broken Window Theory.

In the Broken Window Theory you have a boy walk by a sweater shop, and he tosses a rock through the glass. Some economists say this is good for the economy, because it creates a job for the glass maker. What is not seen is the effect on the sweater maker.

During the time the window is broken, the sweater keeper is not allowed to sell any of his sweaters. He therefore is out of a job until the window is fixed. He makes zero sweaters.  If he sells zero sweaters, the sweater maker sells zero sweaters.  Various other unseen people are also affected, such as the delivery man, and the man who sells little gadgets to support his family.

But the people don't see this aspect of the economy, all they see is what is obvious: a broken window and it being repaired. They see that the repairman is making money.  They think this is good for the economy. It is, but what they don't see is that the sweater company being closed greatly effects the economy in an unseen way.

So, I guess I'm comparing useless ventolin therapy with the sweater salesman. While the patient and the physician see the breathing treatment, what they don't see is that it did no good. Regardless, studies show that 50% of patients who received a placebo also said they benefited from the patient. So this proves that the patient is unreliable.

Likewise, in a similar scenario, while the breathing treatment is being given, the patient is given lasix. While the lasix is forming pee, and thus removing fluid from the lungs, thus making it easier to breathe, it is not seen.

In this way, lasix is also like the sweater maker. Since the ventolin is seen, it is given credit. It is also like the primitive medicine man getting credit for saving the live of a patient, when the truth is that nature did the same. But since he did something, he is given credit.

Also, and I'd like to see a study on this, when an RT is burned out at the end of a day due to too many frivolous therapies, it diminishes his ability to make good decisions at the end of his shift. A burned out therapist is not always at the top of his game.

This, in my opinion, may work to the detriment of good patient care. A burned out RT who is grumbling and griping at yet another useless ventolin order is probably not good for public relations either. And it's not like you can fire this RT, especially, as I've observed, this is common among all RTs. So you can't fire them all.

Now, these are simply thoughts. Although in all the years I've communicated such thoughts, I have never had anyone come up with a counter argument. Not one person has ever come up with any facts to prove that ventolin is needed for CHF, pneumonia, cancer, pleural effusion, and other lung diseases that provide asthma like symptoms.

I have had many doctors say things like, "I think that ventolin helps with heart failure." I ask this doctor, "Do you have the evidence to support this claim, or is it just a feeling?" Never has a doctor proffered any evidence. Usually they get mad as I offer my proof. They get mad at me for being honest.

Getting back to the broken window theory, as I'm giving the breathing treatment that isn't needed, what is not seen is that two rooms down is a man in the early stages of heart failure.  He is the man I would be visiting if I wasn't stuck in this room. Later on he will be intubated, and and only because of that breathing treatment that was thought to do no harm.

The idea that ventolin therapy does no harm, in my opinion, is no better than treating diseases the primitive way with a medicine man dancing, rattling his shakers, beating his drums, and chanting incantations. Since this is what the sick person sees, when the patient gets better the patient will say, "The miracles of the medicine man cured my sickness."

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The worse part of having 30 patients on treatments

The worse part of having 30 patients on breathingi treatments, with 28 who don't need them, is that I don't care about conversing with my patients the way I usually do.  My sole MO is to dole out nebs (yes, to be a neb jockey, or the nurses bitch).

The patient wants to start a conversation with me, and I feel guilty, but I'm so burned I can't even crack a smile.  My wife says I should be happy to do this, because I get paid to dole out stuff that's not needed.  But even that doesn't do it for me any more.  I just feel so pointless when I'm working like this.

Every room I go to, every doctor I talk to, every nurse I talk to, I keep coming up with ideas for my blog.  A doctor says, "I want to change that QID treatment to Q4 around the clock."  Why?  I just got done doing a treatment on that patient, and he was neither short of breath nor wheezy nor dim.  WT?.

A nurse comes to me and says, "I need you to give a treatment to the lady in room 33245234."

"Why?"

"Because she's wheezing."

"Is she short of breath?"

"No, but she sounds bad."

"She always sounds bad," I say.

If I walk away now the nurse thinks I'm lazy.  I once got written up because I didn't do what the nurse wanted.  So I go in the room and find a patient sleeping in no distress with an audible wheeze.  I say to the nurse, "If it's audible, it's not bronchospasm.  It's a cardiac wheeze.  It's in her throat."

But this is the 3,343,343,342,563,645,754 time I've explained this to this nurse, so I know this information is going to bounce off her gray matter like a rubber ball on cement.  So I do the treatment.  Yes, I'm this nurses bitch.

(Trust me, most nurses aren't this way.  Although when you're burned out is always (generalization) seems that such annoying nurses come out of the woodwork).

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The great RT dilemma, as noted by one of you

One of the things I wish I could get my readers to do is write their names when making a comment, or even give me a fake name.  Of course I understand why you guys and gals don't give names, because you don't want to get into trouble.  I duly respect that.  And that's the only reason I leave you with the option of responding anonymously.  

So, while I cannot give the person who left this comment due respect, I believe he or she has made a great point, and a point worthy of a discussion.  The comment went as follows: 

Respiratory Therapy is a strange profession in that we often take our orders from people who know less about our field than we do. Doctors go through 4 years of college, 4 years of med school, 3-7 years of residency... but they have to know about gallbladders and kidneys and glandular issues and depression, among other things. 

We get a fraction of the schooling and training, yet it is all about one subject and becomes more in depth on that subject. So we take orders that we know are wrong or not ideal, and we learn to take it with a smile. It's an interesting concept. Often, disagreeing with ICU nurses and ER nurses can get RTs in trouble.

It's no wonder that many RTs just stop learning and become doers rather than thinkers... what good is that knowledge if it you're just going to defer to someone else and do what you're told? What good is that knowledge if other RTs will just see you as a show off?

I'm just going to leave it at that and let you folks ponder the thought.  Once you've rolled the idea around in your minds a while, or have discussed it among your fellow RT buddies, leave a comment below.  I'm just interested to learn your take on this.  Please feel free to complain, but hold off on obscenities.

If you're the brilliant RT who wrote this comment on "Low information doctors," you're probably smiling right now, and maybe even surreptitiously covering your smile.

RT history: All SOB still treated as asthma

You see me write often on these pages about how Ventolin and Xopenex and Atrovent are -- much like Tylenol -- given to patients way more often than they need to be. Like tylenol, bronchodilators are among the most abused medicines on the market.

Yet there is a historical reason behind this abuse. If we go back just 50 years you'll see many myths about asthma, and many myths about asthma treatments. Well, if you've ever heard the myth that chicken noodle soup will cure the common cold you'll understand where I'm coming from.

Actually, a really good example of how history can effect how we think today all you have to do is look at the history of the name of America. We know that Columbus discovered America for Europe, yet America was named after Amerigo Vespucci.

The king of Spain had it named so because Columbus didn't write about his ventures, Amerigo did. Years later when it was learned Columbus discovered America first historians tried to change the name to Columbia, but by then it was too late: the name America was already firmly planted in the minds of many.

So you can see it's hard to change old thinking, even if it's wrong.

If you read books about asthma that were written prior to the late 1990s, you will not see asthma defined the same way it is today. In fact, asthma, as defined prior to the 1930s may not even be asthma at all.

Now I'm sure Teddy Roosevelt had the disease, yet even physician's like J.B. Berkart, who wrote his version of "On Asthma: It's pathology and treatment" in 1878 noted the following:

"ALL early historical traces of the affection at present called asthma are lost. Although the disease is said to be mentioned in the Bible, and described by Hippocrates, Areteaus, Galen, and Celsus, there is not the least evidence that those remarks apply to the asthma of to-day. For in the former systems of medicine, all cases presenting the same conspicuous symptoms were, regardless of their anatomical differences, considered as of a kindred nature, and grouped into classes according to imaginary types."

In this regard, any disease that caused shortness of breath, or dyspnea (being winded) were all called asthma. Chronic bronchitis, emphysema, COPD, cystic fibrosis, pneumonia and heart failure all result, at times, in symptoms similar to asthma, and, thus, were all grouped in the class of asthma.

Now, it should be important to note that since this is the old way of thinking, it only makes sense that many doctors STILL often confuse these diseases, and often treat all that wheezes and all that causes shortness-of-breath as asthma. So now perhaps you'll understand why I often make fun of this on this blog.

The funny thing is, that even while Berkart noticed this, he himself believed asthma was caused by Rickets, and he also believed asthma was psychosomatic. Likewise, he himself said that he had never performed an autopsy on an asthmatic and not seen emphysema. Emphysema, as you and I know today, causes permanent air trapping in the lungs, while asthma causes air trapping only during an exacerbation (with a few exceptions). Yet that wisdom is relatively new.

During most of the 19th century asthma was thought to be a psychosomatic disease, in that asthma experts believed asthma was all in the head of the asthmatic. With good psychiatric care, and good medicines like opiates and caffeine, one asthmatic was expected to relax and the asthma attack will go away, and asthma itself will go away with age (a fallacy that still exists).

In fact, there are and were (are) so many asthma myths that I can hardly scratch the surface, although I try in this post.

I have also observed that once science proves something to be true, it usually takes about ten years to convince physicians at larger hospitals to change. Then, once larger hospitals adapt new policies based on facts (which may take up to 10 years), it takes another 10 years for smaller hospitals (like Shoreline) to catch on.

So, you can see, progress is slow. While the wisdom may be out there, progress is frustratingly slow.

So this should explain why we are STILL giving bronchodilators for all that wheezes. It also explains why we are still overoxygenating newborn babies even though every study ever done of the subject going on 15 years now shows that oxygen, even to term babies, has been linked to cancer later in that child's life.

I guess this is why they say: patience is a virtue. When you work in the hospital you have to be exceptionally virtuous.

A world of bronchodilator lies!!!

So, have you guys ever wondered why doctors order so many breathing treatments for pneumonia? Slowly but surely we've been learning what doctors are really learning in medical schools. And, for the most part, it's based on a series of lies.

I hate to say it, but it's true. First of all, you've seen the surreptitious Physician's Creed I've been posting on my blog as I obtain pages from my secret sources. Yet recently one of my valued readers emailed me five online articles with the note: "It is hard not to expect doctors to use bronchodilators for pneumonia when articles like these are so easy to obtain."

The first one he sent to me was this one about bronchodilators at Yourtotalhealth about bronchodilators. The worst part about it is this article was approved by a doctor. I hate to say it, but he's either ignorant about bronchodilators, living on another planet, or he's an all out liar.

Here's what the article had to say: "Bronchodilators are medications taken to improve breathing. They help expand the airways and improve the breathing capacity of patients with bronchial asthma, chronic obstructive pulmonary disease (COPD), emphysema, pneumonia, bronchitis and other lung diseases."

So right off the bat this article lies. Bronchodilators improve breathing, but only in patients who have airway narrowing due to bronchospasm. This can be the case with bronchial asthma and chronic bronchitis, but is not true with emphysema and pneumonia.

Emphysema is a disease where the tissues in your lungs break apart. There is nothing that Ventolin does to increase lung tissue. Pneumonia, as I've written a million times on this blog, is a disease of inflammation of the alveoli. Not only are bronchodilator aerosols too large to make it to the Alveoli (Ventolin is 0.5 microns, a perfect size to fit into the bronchioles, but too large to fit into the 0.1-0.2 micron alveolar sacs).

Plus, there are no beta adrenergic receptor sites in the alveoli for the bronchodilator to attach to. And, even if there were, bronchodilators relax smooth muscles in the bronchioles. There are no smooth muscles to relax in the alveoli. Plus a bronchodilator will do nothing to treat inflamed alveoli.

Some doctors claim bronchodilators open up airways of pneumonia patients so they can cough up the junk, but this is a lie too, because pneumonia does not cause bronchospasm unless the patient is an asthma or COPD patient.

Of course the article only gets worse: "Bronchodilators also help clean mucus from the lungs to improve breathing. As air passageways are opened, mucus moves more freely because it becomes thin and can be coughed out more easily."

Where's the scientific proof to back this up? What study was ever done that proves bronchodilators clean mucus from the lungs. Of course, that is why we RTs joke that doctors think Ventolin works like scrubbing bubbles, in that it gets deep down in the lungs, suds up like soap, and gives the lungs a nice washing.

Of course, if air passages are not constricted, there is no need to open them (which is the case for most pulmonary patients). Likewise, MUCUS DOES NOT MOVE MORE FREELY BECAUSE IT BECOMES THIN AND CAN BE COUGHED OUT MORE EASILY. Who the hell thought that one up?

Ventolin is not a mucus thinner. In fact, Ventolin has absolutely nothing to do with secretions. If you want a mucus thinner, you have to go to a medicine called Mucomyst, which is a medicine made to reduce the viscosity of secretions. Ventolin does not.

The article states, "They work by relaxing the bands of muscle surrounding the airways." This is correct. By reading his own article this doctor should have realized what he said above was not true. And we wonder why Ventolin is the most abused medicine in the entire hospital.

Just reading this one article ticks me off so much I don't even want to waste my time with the rest. Here, I'll let you check them out though. Perhaps you can write the authors and ask them where they get their proof for their claims. Or is science not a part of medicine anymore?

This article from Allina Hospitals and Clinics describes Xanthines like Theophylline (Theodur) as a bronchodilator that treats pretty much any lung condition, including pneumonia. Of course we know it's a bronchodilator, meaning it dilates constricted bronchioles and that's it.

My anonymous source writes, "Then this study for antibiotic use for pneumonia suggested that more bronchodilator use may be needed especially in patients that have a prior history of bronchodilator use. I know that I don't have a medical background and probably don't truly understand this study, but how do we fight against this type of information?

Likewise, she writes, "I do agree with you about the bronchodilator fallacies, but there is a lot of literature that sure confuses the rest of us non-medical folks."

Let's consider that final study first. Here a study was performed to see if a bronchodilator breathing treatment would be as efficacious as using antibiotics to treat childhood pneumonia, which is often caused by a virus. The conclusion was this: "Treating children with non-severe pneumonia and wheeze with a placebo is not equivalent to treatment with oral amoxycillin."

First of all, antibiotics, like bronchodilators, are of no use when it comes to treating viruses. It's like pouring tap water on a wound and saying it's disinfected. Basically, this study is saying that 100 pneumonia patients were treated with a bronchodilator and they all eventually recovered. There's no scientific basis behind this study. It's poppycock.

It's studies like this that have us still using Chest Physiotherapy in hospitals. One study 50 years ago showed that 100 post operative patients were given CPT and they all recovered. So from then on it's ordered on all post operative patients. It's all based on poppycock studies, and it's given merit too.

So basically this study shows that bronchodilators are just as ineffective for childhood pneumonia as antibiotics. Although the results were interpreted otherwise.

Well, I understand how this can be confusing. Doctors, nurses and even RTs are confused about what bronchodilators do. It's not just a few, because I'd say about 80% of all bronchodilators given in the hospital are not indicated. I know, because I'm standing by the side of the bed before, during and after every single treatment a patient receives in the 12 hours I'm on duty.

Because I've been using bronchodilators for 40 years and have never once used it for anything other than for bronchospasm. And because I do my research and have studied bronchodilators ad nauseum. Something doctors don't do. And that's fine. But it would be nice if they would admit their ignorance instead of denying it and letting it go to their head. Instead of doing that, wise doctors and hospitals are going more and more to RT driven protocols so we RTs can use our experience, wisdom and education to the benefit of not just the patient, but the hospital too. Can you imagine how much money would be saved if stupid bronchodilator orders were even cut by 25%? It would be millions of dollars.

It seems to me that too often in this life we do things the opposite way we should in medicine. It seems to me that we'd be skeptical to give a medicine for a disease until it is proven to be effective. But, in medicine, we don't want to spend too much time or money on research when we can just give the medicine and CHOOSE to believe it is doing something. And then we have to deal with the consequences no matter how harsh those consequences are.

What's going in with healthcare reform is another perfect example. Here we pass all this healthcare reform while we have zero, zilch, nada evidence that it will actually work. Which is why it's sometimes better to do nothing than to do something we think is good but we don't really know. What we really should do is leave it to the experts. When it comes to bronchodilators, the people in the room assessing the patients are the true experts.

Yet that's not what happens. Those in Washington didn't vote for healthcare reform because there is proof it will work. They passed it because it makes them feel good. It makes them feel like they're helping people. It doesn't matter if there's evidence it won't work or not: it makes them feel good.

That's the case with bronchodilators. We give them for every respiratory disease, every patient who is short of breath, every irritating lung sound, and doctors and nurses and even some RTs simply feel good that we are doing something, and they CHOOSE to believe the medicine is doing something for them.

It's kind of like the lady who's given laxis and a bronchodilator because she had heart failure and was in pulmonary edema. Five hours later she says, "Wow! That breathing treatment really helped." See, this patient saw the bronchodilator so she gave it credit. The same is true for doctors and nurses. They give credit for what they CHOOSE to believe helped the patient. When the rest of us know it was not the bronchodilator that helped the patient. The bronchodilator did nothing but add more fluid into that patient's lungs. The real credit goes to the Lasix, which helped the patient pee out the excess fluid from her body and lungs.

Of course we intelligent folks know that cardiac asthma must not be confused for asthma. The patient can get them confused, but we medical workers never should -- yet there are those amongst us who do all the time.

Allow me to say here, folks, that the battle for bronchodilator reform is not going to be won over night. It's going to take no longer being enablers for doctors and nurses. We need to quit just giving the treatments, and we need to educate one doctor and nurse at a time.

Although, the only problem is we are merely humble RTs who want to keep our jobs. So quite often it's better to keep our mouths shut and do what we are asked rather than try to change ignorance we have no control over.

For more information on how doctors abuse bronchodilators, see my Physician's (Doctors) Creed in the links above, or click here. Click here to read more about bronchodilator reform. Click here to read about the benefits of RT Driven Protocols. Click here to read my apology for my tone in this post, and my apology to the websites and doctors above mentioned.

Here's why we give unindicated nebulizers

In the past week I have seen the following written in two different books on asthma: "All that wheezes is not asthma."

Likewise, all studies I've ever seen show that an MDI with spacer works equally well as a nebulizer, and the asthma guidelines recommend using an MDI except for cases of severe breathing exacerbations.

I mentioned this to my coworker, and asked her this question: "Don't doctors read this stuff. Don't doctors get these books?"

She said, "Yes they do. But people expect when they come to the ER, or get admitted to the hospital, that we are going to do something. Giving them the breathing treatment as opposed to just an IV and a bunch of pills makes the patient feel like we are doing something."

That about explains it in a nutshell. That's 50% of the reason why we do bronchodilator breathing treatments on every person who comes in with a wheeze or any respiratory ailment. There are other reasons though. What follows are the real indications for bronchodilator breathing treatments:

1. To make the patient feel like we're doing something. (20% of treatments)
2. To make the doctor feel like he's doing something to help the patient (20% of treatments)
3. To create a procedure so the respiratory therapist doesn't lose his job. (20% of treatments)
4. To meet admission criteria (20% of treatments)
5. Bronchospasm (20% of treatments)

There you have it. Now if you add up the percentages that I just made up, you have 20% of the breathing treatments we do are indicated, and 80% are not indicated.

In other words, most therapies we do are because of the government, big companies and doctors who don't care about wasting money.

Reason for most needless treatments

Some RT departments have RT driven protocols. This, one would think, would be the ideal way of preventing needless therapies. However, most RTs who work at hospitals that have such protocols note that, "I discontinued the therapy only to come in the next day to see the order was rewritten."

Either that, or senior RTs refused to discontinue un-needed therapies. Why would this be? Well, the answer appears to be obvious: It's called criteria. In order for the hospital to get reimbursement, certain criteria needs to be met. At least this is according to my RT Boss.

For example, if a patient is admitted with pneumonia, most insurance companies (and the government) will not reimburse the hospital unless a breathing treatment is ordered. By golly, if a patient isn't sick enough to need a bronchodilator they don't need to be admitted.

This is funny (irritating would be a better word), because some person in Washington who had no clue what he or she was doing made this decision, when the truth is that bronchodilators have no effect on the inflammation in the alveoli that pneumonia is. Bronchodilators don't even get down into the alveoli.

Regardless, this pretty much explains some of the stupidity. This is why we have a pneumonia protocol (order set I call it) that requires all pneumonia patients to receive Q6 hour Ventolin.

Yes this is frustrating, but it's the way it is.

Wheeze no longer indication for bronchospasm?

I've come to the conclusion that a wheeze should be removed from the list of indications for a bronchodilaotr, and replaced by the word "diminished lung sounds."

The reason I say this is the word "wheeze" is too subjective, and prone to lead to questionable breathing treatments or bronchodilator abuse. Bronchodilator abuse is when bronchodilator breathing treatments are ordered for patients not having bronchospasm.

The following is a list of noises that are not true wheezes:

1. cardiac wheeze
2. upper airway wheeze
3. stridor

Likewise, there are other disease processes that can cause a wheeze, such as a pulmonary embolism, cardiac asthma (CHF) and lung cancer.

Therefore, due to the fact the word "wheeze" is too open to subjective opinion, I hereby petition it be removed from as an indicator for a bronchodilator order.

In place of wheeze I would like to see the word, "diminished lung sounds." I say this because if you listen to a patient and he has good air movement, you can be pretty assured he is not having bronchospasm -- even if you think you hear a wheeze.

Perhaps this might result in true bronchodilator reform.

Bronchodilator Reform: Part II

After I wrote about Bronchodilator Reform as a quest post at Respiratory Therapy 101 last February, I decided this post needed a follow up. And thus is what inspired the following post:

Bronchodilator Reform: Part II
By Rick Frea: February 25, 2009 @RespiratoryTherapy101

So we are in a healthcare crisis caused mainly by skyrocketing healthcare costs. Perhaps one of the culprits of this crisis is something RTs have been vying against for years — bronchodilator abuse. Shockingly, few have listened to our cries for reform. Perhaps, however, money will talk.

While important officials often go to hospitals looking for procedures and therapies that are no longer needed in order to save money, never do they set their beedy eyes on the respiratory therapy department where millions of dollars are wasted every year on frivolous treatments.

While Ventolin breathing treatments may not be the only cause of rising healthcare costs, they are a major contributing factor. In a pithy manner I will explain.

By now you know Ventolin is ordered by many doctors for all annoying lung sounds, and many patients who are short of breath regardless of the cause. That is what they do despite the fact Ventolin is ONLY indicated for shortness of breath due to bronchospasm.

Now you might be asking: what do useless breathing treatments have to do with the healthcare crisis. Well, consider the following.

Where I work treatments cost $84 a pop. I estimate (on the conservative side) that 80% of Ventolin treatments ordered are not indicated and thus are non-beneficial to the patient. You can see, Houston, that we have a problem.

You do the math. Say the average hospital gives 40 breathing treatments during one 12 hour shift. That’s a total daily profit just from Ventolin treatments of $3,360. So you can be certain here we will not have hospital adminstrators on our side in our battle for bronchodilator reform.

But, when you consider who is paying the cost, officials might want to be aware that (80% of $3,360) $2,688 each day is going to this one non-indicated procedure. Multiply that by 365 and you gett $981, 820 wasted on Ventolin Abuse at just one hospital.

Multiply that by all the rest of the hospitals in the U.S. and that’s a lot of wasted money. Plus, mind you, I’m being conservative. The actual amount of money wasted on Ventolin therapies is more likely much higher.

Yet, still, when important officials go to hospitals demanding cuts in un-needed procedures, rarely ever do beedy eyes peer into the RT department.

Indications for breathing treatments

Since I write so often on these pages reasons nurses call for breathing treatments and doctors order them (my latest version is here), I think it is due time I create a list of the true indications for a bronchodilator breathing treatments.

Keep in mind a bronchodilator only treats bronchospasm. Likewise, rescue inhalers used properly with spacer are proven to be as effective in most cases as a breathing treatments.

That in mind, here we go:

1. Asthma
2. Bronchitis (acute or chronic)
3. Emphysema (actually, this is not a true indication)
4. Cistic Fibrosis
5. Airway swelling due to allergic reaction (actually, bronchodilator doesn't treat swelling)
6. Pt with above diseases who cannot manage an inhaler (Albuterol, Atrovent, Flovent, etc.)
7. Bronchospasm secondary to other disease process such as CHF, pneumonia, pulmonary fibrosis, RSV, lung cancer, sinusitis, bronchiectasis, etc.
8. Bronchospasm secondary to allergic reaction (bee sting)

Note #1: The diseases in #8 do not necessarily cause bronchospasm, but may irritate the sensitive airways of people who have the diseases mentioned above

Note #2: It appears doctors believe treatments are cures for all ailments, and are indicated for all the wheezes and all that causes shortness of breath as you can see for yourself by reading the Real Physician's Creed.

We'll make this RT Cave Rule #25: A wise medical care worker will know the indications for ordering a breathing treatment and not request a treatment (or order one, or give one) unless a patient meets this criteria.

Note #3: Again, I am going to file this under humor, although it is not humor it is serious. Too many doctors fail to understand the true indications for breathing treatments

28 non indications for breathing treatment

Just a friendly reminder: the following are not indications for bronchodilator breathing treatments:

1. Dr. ordered it
2. Don't know what else to do
3. Nurse wanted it
4. Pt wanted it
5. Stridor
6. Sinusitis
7. Mesothelioma
8. Lupus
9. Laryngospasm
10. Audible wheeze
11. Rhonchi
12. Crackles
13. M.S.
14. Homeless
15. Depression
16. Pt has home nebs
17. Pt likes tx
18. Pt likes company
19. Bed ridden
20. History of smoking
21. Irritating lung sounds
22. Low SpO2
23. Trach
24. Intubated
25. Post operative
26. Atelectasis
27. Fever
28. Heart failure
29. Cardiac wheeze
30. Pneumonia
31. Pleural effusion
32. Pneumo
33. Rickits
34. RSV
35. ARDS
36. RDS
37. P.E.
38. Cough
39. Sputum induction
40. All wheezes (all that wheezes is not bronchospasm)
41. All SOB (SOB is not always caused by bronchospasm)
42. Just because the patient is wearing a mask

Here are 12 diseases Albuterol does not benefit

As many of my readers know from reading my past entries Albuterol (and Xoponex> an too) is perhaps one of the most abused medicines in the hospital. While it is a bronchodilator designed to help asthma and COPD patients catch their breath, it is often ordered for diseases that have nothing to do with bronchospasm.

The truth is, Albuterol is a bronchodilator and nothing more.

It's so bad that my Rt coworkers and I often joke that doctors believe in the theory that, "All the wheezes should be treated as bronchospasm (or asthma)," or, "If he's short-of-breath he should get a bronchodilator breathing treatment," or, "If it's a disease in the lungs, a bronchodilator is indicated."

The truth is, all that wheezes is not bronchospasm, and all illnesses that cause shortness-of-breath are not indications for a bronchodilator, and all illnesses of the lungs are not reasons to order Albuterol. Yet that often seems to be the case, as you can see by this post.

What follows are ten common ailments patients are diagnosed with that often cause a doctor to order braething traetments for when a breathing treatment is not indicated and will have no effect on the disease.

1. Pneumonia: Pneumonia is inflammation in the alveolar sacs. Ventolin is 0.5 microns, and the Alveoli are 0.1 to 0.2 microns -- Ventolin can't even deposit into the lungs. And, if by some osmosis process it did make it down that far, it won't do anything anyway because Ventolin does nothing for inflammation, and it will not remove fluid from the lungs. For more information, check out this link here.

2. Cardiac Asthma (CHF, pulmonary edema): I wrote a good article about cardiac asthma a while ago, and I will link to it here. Albuterol does does not heal the heart, and it will not reabsorb fluid from the lungs.

3. Respiratory Syncytial Virus (RSV): This is a virus that causes swelling of the airways and increased secretions in neonates. Studies have been done that prove a bronchodilator is of no use, unless there is an underlying bronchospasm. Likewise, studies show sometimes racemic epinepherine is beneficial to these patients. In most cases, though, studies show simple suctioning of the nares usually clears the lungs before a treatment is even given, making it so a treatment is no longer indicated. I wrote an article about this here and also here.

4. Pneumothorax: This is a restrictive disorder otherwise known as a collapsed lung. It may cause severe shortness of breath, but once a chest tube is in place the patient may breathe just fine. Regardless, because it takes place in the lungs, a bronchodilator is often ordered.

5. Pleural Effusion: Again, fluid buildup around the lungs is a restrictive disease that lessens the ability of the lungs to stretch. Since this process takes place outside the bronchioles, shortness of breath caused by it will not be benefited by a bronchodilator.

6. Lung Cancer: Lung cancer can cause a wheeze because the cancer can put pressure on some bronchioles causing them to become narrowed (squeezing them), and thus they whistle. Since the narrowing of the bronchioles is isolated to one area of the lungs, and the cause is outside the bronchioles (a restrictive ailment), a bronchodilator will be of no use.

7. Fever: I think the theory behind doctors ordering treatments for fever is that they think it's caused by atelectiasis, and that the bronchodilator will somehow reinflate the alveoli. As we now know, Ventolin is too large in size (0.5 microns) to get into the alveoli. And, even if it somehow could get down there, it has no chemical properties that allow it to blow up flat alveoli like a tire pump blows up a flat tire.

8. Atelectasis: See Fever above. Some doctors see atelectasis, or hear it upon auscultation, and assume a breathing treatment will be of some use. Ventolin will not reinflate deflated alveoli.

9. Post operative (prophylactic): One of the surgeons at Shoreline Medical once told me he ordered postoperative breathing treatments because they keep the lungs "clean and open." For this reason one of my co-workers jokes that doctors think Ventolin works the same as Scrubbing Bubbles in that it suds up in the lungs and washes away any crud that might be in the lungs. The truth is, if there is no bronchospasm, a bronchodilator is of no use to the post operative patient.

10. Airway congestion, colds, or influenza: Stuffiness caused by congestion caused by head and chest colds will in no way go away with Ventolin. It will also not clear a stuffy nose. However, it is often ordered for this reason. However, if these ailments may compound asthma and COPD.

11. Meet criteria: This is not necessarily a disease, but it might as well be. Many treatments given in hospitals are not ordered because they are indicated, but because they are needed to meet criteria for reimbursement. Recently I wrote about this over at RT 101. I also wrote a recent post (click here) guestimating how much money is wasted doing non-indicated breathing treatments

12. Pulmonary Embolism: I just about overlooked PE, so here I must add it to the list. A PE is a blood clot that formed in the legs or elsewhere in the body, dislodged, and finds it's way to the pulmonary artery in the lungs and bocomes lodged there. Many times a patients may have two or three PEs at one time. It usually causes symptoms such as crackles, shortness of breath, cough, rapid heart rate, wheezing, leg swelling, anxiety and fever. A PE can usually be discovered via testing, and once the symptoms are figured to be a PE no further breathing treatments should be given. This disease is a good examle of: All that is short of breath is not bronchospasm.