Should loved ones watch a Code Blue?

There's an interesting article I found at nursetogether.com by Julia McConnell called "Code Blue: Should A Loved One Watch?"  My gut instinct upon reading this title was: why would they want to? I mean, we're going to invade every piece of privacy that person has, and it's not pretty.  To watch that on a loved one would cause more grief than it's worth. 

Then again, I watched as my mother-in-law was being intubated, and my wife was in the room too.  We are both medical people, and we wanted to be there for her.  However, what good did it do?  It's just another memory that's never going to go away. 

On the plus side, though, it provides us both with some reassurance that everything was done and done right.  The doctors, nurses and respiratory therapist did everything they could, and they did it right.  That alone provides some reassurance.  Yet for someone whose not medical savvy, I can see no benefit from watching. 

Although, I think it should not be up to the medical professionals to decide.  If a family member wants to watch, so be it.  I would, however, recommend that they not watch.  I would kindly ask them to step out, although I would say that it's up to them.  We're going to be doing some things to your loved one that you might not want to see.

I think McConnell says it best as she writes:

I will venture to guess that family members who would opt to watch imagine that it will be just like on TV — quick and clean with a happy ending. They need to be told it’s not like their favorite TV drama. It’s a long, drawn-out battle:  blood, cracking bones, shouting, loud beeping, lots of needles and extreme roller-coaster-style energy — anger, joy, tears, smiles, terror, relief, frustration and exhaustion... The team does their absolute best to have a positive outcome and this might be the sole reason for a family member to watch. They’ll see the dedication and effort that went into the attempt to save a life.

Plus, when the family is watching, codes tend to last a lot longer. More sweat is used in CPR and bagging, more doses of epinephrine are inserted into the patient, and this is often done despite the people running the code knowing what the result will be.  Then, at some point, the doctor will say, "Well, does anyone else have any ideas?  I'm open to suggestions."  When you hear that, and no one has any answers, you know the outcome: "Okay, everyone can stop!"

Sorry to say, codes are not pretty.  I would recommend loved ones not stick around, yet it's their decision -- as is the way in our great nation. 

Heart Attacks increase during Christmas season

By far I am behind in my blog reading, yet I happened to check out COPD News of the Day to learn what I had already suspected, that the risk of heart attacks are up by 5% around the Christmas season.

She sites this article from Health.com which states that while ERs tend to be relatively slow on Christmas day, and patients opening presents don't even know they are at high risk for a heart attack. Yet many are.

The article notes that December 26 is one of the most hazardous days of the year for people "vulnerable" to cardiac problems such as heart attacks, arrythmias and heart failure (CHF).

The article also sites a 2004 study that showed heart related deaths increased about 5% around the Christmas season, the article notes, " perhaps because patients delay seeking treatment for heart problems or because hospital staffing patterns change."

I personally don't think it has anything to do with hospital staffing patterns. I think it has to do with modest patients thinking they are impervious and humble and delay seeking treatment for their seemingly life threatening condition.

I have written on my blog before how people simply don't want to be inconvenienced by doctors and medical stuff. It's not abnormal at all.

I've also noticed how the hospital tends to be ironically slow during the Christmas season. And while I'm working the days following the Christmas until after the New Year's Celebrations I expect there to be one or more cardiac patients being wheeled through the ER doors.

It's just a fact of life.

The resolution to this problem is the same as any other, and involves education. The more people are educated the more likely they will seek treatment.

Yet sometimes even us well educated delay seeking help, and in this case a good supporting cast of family members is essential to getting the good health care you need.

Just remember it's your life. It is up to you to take care of yourself. When you notice any of the following signs of heart problems call your doctor immediately, or have yourself taken to an emergency room ASAP:

Signs of heart problems include:

1. Chest discomfort. It can stay or go away and come back. Generally it goes away and comes back.
2. Uncomfortable pain in chest
3. Dull pain in chest
4. Squeezing pain in chest
5. Full feeling in chest
6. Jaw pain
7. Left arm pain (most common)
8. New onset back pain
9. Stomach pain
10. Right arm pain
11. Nausea
12. Heart Palpitations
13. Shortness of breath
14. Breaking out in a cold sweat
15. Light headedness
16. No symptoms at all

If you even notice one or a few of these symptoms you best be getting your heart to the emergency room. It's best to come in and be told you are fine than to stay home and hope you are fine.

We will not make fun of you for coming into the ER. In fact, just the opposite: we will respect you for taking the proper action when your body is feeling or acting funny.

I believe it is very rare for someone simply to drop dead of a heart attack without that person first showing and then perhaps ignoring the signs and symptoms. Take care of your body and your heart, and know the signs above.

Do this even if you are in good health. If you don't save your own life, perhaps you can use this information to save the life of a friend or loved one.

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New study shows outdoor wood stoves unhealthy

When I was a kid my parents decided to take the cheapest route home heating and had a wood furnace installed in our basement. This decision might have been good for their pocket books, yet it wreaked havoc on my lungs and therefore my life.

Not only do wood stoves give off smoke that can irritate lungs, but all the wood stacked in the basement was filled with molds and fungus that are known allergens for me and many other chronic lungers. The smoke outside meant I couldn't play out there, and the mold and fungus inside made indoor life equally miserable.

My parents ultimately were told this was bad for me, and there response was to shut off the wood heating ducts to my room and turn on the gas just to heat my room. Yet little did they realize that while this effort was a good gesture, it was frivolous at best.

A new study reported by the Environment and Human Health Inc. as reported here reveals the following about outdoor wood furnaces (OWF):

"Wood smoke contains many of the same toxic compounds that are found in cigarette smoke. Just a few of them include benzene, formaldehyde, and 1,3-butadiene, all three of which are carcinogenic."

In fact, while indoor wood furnaces are a bad enough asthma trigger, "The Northeast States for Coordinated Air Use Management (NESCAUM) found that the average fine particle emissions from one OWF are equivalent to the emissions from 22 EPA-certified indoor wood stoves, 205 oil furnaces or as many as 8,000 natural gas furnaces."

The study also reported the following (PM stands for particulate matter, which is the particle size of the smoke measured):

• A house 100 feet from an OWF had 14 times the levels of PM 2.5 as houses not near an outdoor wood furnace and 9 times the levels of the EPA air standards
• A house 120 feet from an OWF had over 8 times the levels of PM 2.5 as the houses not near an outdoor wood furnace, and 6 times the levels of the EPA air standards.
• A house 240 feet from OWF had 12 times the levels of PM 2.5 as the houses not near an outdoor wood furnace and 8 times the levels of the EPA air standards
• A house as far away as 850 feet from OWF had 6 times the levels of PM 2.5 as the houses not near an outdoor wood furnace and 4 times the levels of the EPA air standards.
• High levels were present in every 24-hour period tested inside homes neighboring outdoor wood furnaces
• All houses tested had particulate exposures well above the EPA ambient air quality standard.
• Levels of PM 2.5 that exceed the EPA standards are associated with asthma or chronic obstructive pulmonary disease (COPD) attacks and hospitalizations, and are also associated with increased risk of cardiac attacks.
• Particles of wood smoke are so small that windows and doors cannot keep smoke out
• A study by the University of Washington, Seattle, showed that 50 to 70 percent of outdoor wood smoke entered homes that were not burning wood.
• Because wood smoke particles are so small, they are not filtered out by the nose or the upper respiratory system. Instead, these small particles end up deep in the lungs where they can cause structural damage and chemical changes.
• Carcinogenic chemicals and wood smoke irritants adhere to the small particles and enter the deep, sensitive regions of the lungs where toxic injury is high.

The short term, or "irritable" side effects of inhaling smoke from outdoor wood heaters include:

• Night time coughing
• Headaches
• Inability to catch breath (dyspnea)
• Burning throat
• Burning eyes
• Bronchitis
• Pneumonia
• Colds
• Increased respiratory infections (particularly in children)
• Missed days of work or school
• Emergency room visits

The long term side effects of inhaling from outdoor wood heaters include:

• Increased risk for lung cancer
• Asthma
• COPD
• Cardiovascular problems
• Carbon monoxide poisoning

In fact experts note that "Even episodes of short-term exposures to extreme levels of fine particulates from wood smoke and other sources, for periods as short as two hours, can produce significant adverse health effects."

The particulates breathed in are not only linked with chronic lung disease but to lung cancer, as evidence shows the smoke inhaled also contains known carcinogens. So short-term exposure may result in either asthma, COPD, and long term exposure to those plus lung cancer.

So smoke from indoor and outdoor wood furnaces have the same known harmful chemicals as cigarette smoke, smoke from outdoor wood stoves is thicker and more prevalent in the air, and is more "pervasive for those who live near them," said Dawn Mays-Hardy of the American Lung Association, New England.

Likewise, "Resident of Environment and Human Health, Inc. Nancy Alderman says, "EHHI has now shown that wood smoke from outdoor wood furnaces enters neighboring houses in high enough amounts to cause serious health impacts to these families. States can no longer ignore this science and should ban outdoor wood furnaces until safer technologies are found."

Is your doctor out of date?

"Is your doctor out of date?" That's a valiant question, and the title of a Reader's Digest article from the November, 2009, issue.

Of interest to learn is that while asthma used to be treated as an acute disease, whereas doctors would wait until an asthmatic had an attack and treated the symptoms, asthma experts now recommend using asthma controller medicines, preferably inhaled corticosteroids, to PREVENT asthma.

Yet, evidence shows that only 50% of the 9 million asthmatic kids are currently on inhaled corticosteroids, either because their doctors didn't prescribe them, or they weren't told to continue to use them when they were feeling well.

The old way of treating high blood pressure was to tell people to eat better and live better, although the new method is to make sure any person who has a blood pressure higher than 140/90 you need to be on one or more blood pressure medicine to bring it down to normal.

Past evidence showed that less than 10% of those with high blood pressure made the necessary changes to lower their blood pressure, which is why the "guidelines" for treating high blood pressure were changed.

It used to be that for those with back pain, an x-ray was taken, perhaps an MRI, and sometimes even invasive surgery was performed. Yet, evidence shows none of those ever did any good, and often resulted in unnecessary and painful procedures that did more harm than good.

New guidelines focus on encouraging exercise and heat pads to overcome the pain, and only going the next step if there is severe weakness, a history of cancer, or problems urinating.

While evidence show clot busting medicines like Asprin, angioplasty and other "proven steps" have been proven to make a big difference in outcomes of those having a heart attack, evidence shows fewer than 50% were getting clot busters, and 25% referred for other treatment.

Since then efforts have been made to get the word out.

All humans are creatures of habit, which makes all of us, in a way, set in our ways. This is why experts have come up with guidelines that are updated, and have made efforts to continually educated not just doctors, but patients and family members to.

As noted by the article, "when your doctor suggests a treatment, you should hear the word evidence in his or her explanation."

Yet, still, a guideline is still a guideline. There are times when common sense should prevail. A good example is the asthma guidelines, which state if you use your rescue medicine more often than 2-3 times in a week your asthma is not controlled.

But sometimes you have a hardluck asthmatic who does all the right things, yet still has trouble with his asthma. In this case, the asthmatic may have good control and still require to use his rescue medicine a few times a day.

So, is your doctor out of date? He might be, and therefore it's your job to know, to do your research, and to nudge him or her in the right direction if he or she is.

Click here to know if your doctor is doing a good job.
Click here to learn about maintaining a good relationship with your doctor

I'll never forget Mrs. Flowers and her quilt

Way back in October of 2008 Karen over at COPDnewsoftheday.com asked me to write a post for her blog about the relationship between RTs and COPD patients in honor of RT Care week. I was honored by her request, and thought instantly of Mrs. Flowers.

The following was first published October 2008 at COPDNewsoftheday.com:

Mrs. Flower
by Rick Frea: October 21, 2008 @ COPDNewsoftheday.com

I was told in report that Mrs. Flower in room 202 was diagnosed with COPD and was having a very difficult go of it. She was only 60. The person who gave me report was concerned that she might be ventilator bait.

So I wasn’t surprised when I was paged STAT to Mrs. Flower’s room early in my shift.
Upon entering her room I immediately observed she was in agonizing respiratory distress. She was gasping like a fish out of water as she sat on the edge of the bed leaning on the table to breathe. Next to her on the bed was an Afghan she had apparently been working on.

“I feel so miserable,” she said, “I… can’t breathe.”

“I know what you’re going through,” I said as I mixed up a breathing treatment.

“NO YOU DON’T!” the patient said.

“Oh yes he does,” someone said from behind me. I turned and saw that it was Tes, a nurse who took care of me back when I was having bad asthma several years earlier. “He has asthma. He KNOWS what you are going through.”

Mrs. Flower looked up at me and managed half a smile, which disappeared in a heartbeat as she concentrated on her breathing. Yet she seemed to mellow at the thought there was a fellow chronic lunger in the room.

With the permission of the doctor, I gave her two breathing treatments. Suddenly, she was breathing normal again — well, normal for her anyway.

Mrs. Flower became one of my favorite all time patients. When she was feeling better — and even when she wasn’t –she’d always be working on an Afghan. When I entered the room she’d stop and take her treatment, and we’d talk.

There were nights I would talk to her for hours not just about COPD and asthma and breathing, but about other things as well. I eventually got to know many of her family members, and she even got to know mine through my descriptions and pictures, as I got to know about her past through her stories and pictures.

Through my 11 years as an RT, there have been many Mrs. Flowers’. Each time I get to know about their entire lives in a few short minutes while I’m helping them breathe better with a bronchodilator breathing treatment.

After she was in the hospital several days, I said, “Well, I’m going to be off the next few days. I’m sure you’ll be home before I get back. So, I hope the next time I see you is in a grocery store.”

She laughed and said, “Absolutely.”

But she came back. At first her return visits were infrequent, maybe once a year. She’d joke and say, “I’m just in for my yearly recharge.”

I think it was about her third visit that I found out she was still smoking, so I discussed with her — as a friend more so than an RT — how much I wanted her to never smoke again.

I explained to her that if she stopped smoking now she won’t be able to undo the damage to her lungs, but it won’t get any worse. She might even improve the quality of her life, and decrease her hospital stays.

She smiled cheek to cheek and promised me she would never smoke again.

Three weeks later she came back for another visit. I didn’t ask her if she was still smoking because I trusted what she told me before. And she went home after a few weeks with our same old good-bye lines.

But eventually she was visiting me more often, and then it got to the point that I said to her, “You might as well move in your dresser you’re here so often.”

She smiled. Even though she was getting sicker, she was still the same pleasant person to talk with, and she continued to work on her afghans.

She went home again. Two days later I finally saw her at a grocery store. Only she was not shopping. She was sitting in her van — smoking.

My heart sank. Of all the things I have seen as an RT, that one moment for me was perhaps among the most disappointing. Here I thought Mrs. Flower was making a gallant effort, and all along she kept right on smoking. No wonder her COPD kept getting worse.

It was kind of a defeatist feeling. I thought I have all this knowledge in my mind that I enjoy sharing, and for a long time after that I couldn’t get myself to share any of it. I thought, “What’s the point.”

Two days after I saw her in the parking lot she was a patient again. This time she was very sick.
She looked defeated. The disease was winning, and she knew it. She was having trouble breathing even while she lay there in her bed. Yet, she still smiled as I entered her room, and stopped whittling long enough to take her treatment and talk.

Out of respect for her, I never said a thing about seeing her smoke. I decided if anything she needs to have her dignity. And I remember when I was a kid trying to stop my grandpa from smoking, and he’d always say, “I’d rather die young doing something I love than to live a long miserable life not doing what I enjoy.”

I thought grandpa died young when he was 70. But he was making a list of things to do when he died, a sign to me that he went out happy.

I thought grandpa’s words rang true here. By smoking, Mrs. Flower was doing something she truly loved to do. I respected that. Yes she was destroying her lungs, but I understood. I didn’t like it, but I respected her.

“You know,” she said one day, “I hope your kids never smoke. It sounds like a cool idea when you are young and think you’re going to live forever, but it catches up to you eventually.”

“When you started smoking,” I reassured her, “The knowledge wasn’t out there. Now-a-days if a kid starts smoking, there is no excuse for it because the education is out there.”

About a year later, after several frequent visits, I learned from reading the paper that she had passed. It was sad, but so is life when you work in the hospital. Yet she no longer had to fight, and she passed the way she wanted: in her own home.

A few days later I was paged to the lobby. “There’s a man here to see you,” the front desk clerk said.

“Who would want to see me?” I thought as I set down the receiver.

In the lobby was Mr. Flower. He held in his hand an Afghan I watched Mrs. Flower make. He said, “This is for you. She finished it just before she passed away, and she wanted you to have it.”
Now I think of Mrs. Flower each and every time I snuggle up in that afghan.

Still, I wonder how many more lives she would have touched with her stories, or how many more afghans she would have made and given away as gifts if she had a few more years to live.

Myth busted: Influenza does not cause nausea!

So, my daughter has been vomiting any food intake the past couple days. One evening I said -- jokingly -- to my wife, "She's probably got that swine flu thing. You know: H1N1."

My wife, wise as wives are, corrected my fallacious statement. She said: "I think that most people get influenza and gastroenteritis mixed up. Influenza is an infection of the lungs, and the stomach flu is what causes nausea and vomiting.

"In fact," she continued, "I think most people who get the flu shot and complain that they got the flu anyway definitely don't know the difference. Because the flu shot you get every year does not prevent the stomach flu (gastroenteritis), it prevents you from getting influenza."

According to HealthCentral.com:

"Influenza, usually known as the flu, is a respiratory infection caused by the influenza virus. The infection typically is spread by air or by direct contact, from one person to another. Most cases occur during epidemics, which peak during the winter months nearly every year. Influenza virus is very contagious. A particularly widespread and severe epidemic is called a pandemic...

"With many other types of infections - for example, mumps - having the disease once protects against a second infection because the body's immune system 'remembers' the returning virus, attacks it immediately and rapidly eliminates it. With influenza, the virus usually has mutated (changed) somewhat since the first infection, but the change is enough to fool our immune system. Instead of attacking the virus rapidly, as it would a virus that it had seen before, the immune system responds slowly. By the time the immune response is in full gear, millions of the body's cells already have been infected with the virus."

It is because the flu virus mutates that you need to get a flu vaccination each year, rather than just once. Each year the vaccination is adjusted to prevent against the current "mutated" strain.

Symptoms of influenza are as follows:

• Chills
• Moderate to high fever (101° to 103° Fahrenheit)
• Sore throat
• Runny nose
• Muscle aches
• Headaches
• Fatigue
• Cough
• Diarrhea
• Dizziness

As I was perusing the web looking for some information on the stomach flu, I came across a neat article at HealthCentral.com called, "Five Myths about the flu," by David Stanley. He writes that when someone says "I have the flu," and is face to face with him, he knows with relative certainty the person does not have the flu.

He gives the person what he calls the Fast Test, which consists of the following questions:

• Fever - The flu typically produces a high fever that lasts three to four days. Fever with a cold is rare.
• Aches and pains - Headache is a trademark of the flu. Other general aches and pains are common as well.
• Sudden onset - A person can go from feeling perfectly healthy to a full-blown case of the flu in a matter of hours. Cold symptoms tend to develop over days.
• Tiredness- If you have the flu and make it to the store to ask me about it, you are one tough cookie. Most people with a cold can carry on, but if you have the flu, do what your body is telling you to do and stay in bed.

So, basically, if you have the real flu you are not going to be out and about telling people you have the flu. Oh, and speaking of "real flu", Stanley writes that influenza rarely causes stomach irritation, and therefore there really is no such thing as the "stomach flu." Thus, if you are nauseous, what you actually have is gastroenteritis, which is an infection of the intestine caused by a different type of virus.

As per all the people I work with complaining that they won't get the annual flu shot because it caused them to get the flu, Stanley clears up this myth:

"This simply cannot happen. The flu shot uses a dead form of the virus to trigger an immune response, and that dead virus cannot come back to life and infect you. If you think your flu shot gave you the flu, first apply the FAST test to see if you have it or just caught a cold. If you do indeed have the flu, one of two things happened: You became infected during the one to two weeks it takes for the flu shot to begin to provide protection.You became infected with a version of the virus not covered by this year's vaccine.

The author, David Stanley, writes: "This may sound odd, but if you say this to me face-to-face at the store, you probably don't have the flu. While people can easily confuse a bad cold with the flu, I use what I call the FAST test to tell the difference. There are four questions to ask to distinguish the flu from a cold:

So, since my daughter is walking around all day with no fever, and playing with her toys, it's highly unlikely that she has the flu. Likewise, if you are having bouts of nausea and vomiting, you don't have the flu either.

And once again the wife was right.

The hypoxic drive theory: Why do we breathe?

(This is part two of a six post series. To return to part one, click here.)

When you are thinking about it, you can control your breathing on your own. Most of the time you are alive, however, you will have other things to think about, yet your breathing continues.

So, how does this work?

(For further reading you can click here.)

There are basically two reasons for breathing. One is to maintain homeostasis (balance) within the body, and the other is for the exchange of gas. By homeostasis I mean maintaining a normal level of oxygen (PO2), carbon dioxide (CO2) and acid base balance (pH or hydrogen ions). By exchanging gas, I mean breathing in oxygen, and blowing out CO2.

According to Donald F. Egan's "Fundamentals of Respiratory Care", breathing is controlled by the Central Nervous System, and originates "in the brain stem, mainly from neurons located in the Medulla Oblongata. For the most part, and skipping a bunch of crummy detail, this gland controls breathing by messages it receives from Chemo receptors.

There are two sets of chemo receptors: the central and the peripheral. The central sit right on the Medulla, and the peripheral are located in the "bifurcations" of both carotid arteries and the arch of the aorta, or somewhere between your shoulders and above your heart.

These chemo receptors send messages to the brain (the Medulla) based on changes in CO2 and PO2. However, for the most part, the main driver of non-spontaneous breathing is carbon dioxide (CO2) way more so than oxygen (PO2).

Allow me to put it simple, when CO2 goes up above a certain point, your breathing speeds up. This is evident quite often in COPD and asthma patients who are suffering an exacerbation. They are having great trouble breathing, and ultimately they start to poop out, and their CO2 starts to build up. Thus, their breathing speeds up.

A normal CO2 is 40. Say it goes up to 100. By this point, when CO2 is 20% or greater above the normal value, CO2 starts to act like a sedative, and slows breathing down. Thus, as CO2 continues to rise, this is a sign doctors watch out for that a person is pooping out, and may need aggressive therapy.

The majority of the time, the central chemo receptors send signals to the brain that control breathing. The peripheral chemo receptors only have a minor roll during normal respirations, and only send a signal to breathe when the PO2 is less than 60. Either way, this response is far slower than the signal sent by the central chemoreceptors. Thus, the peripheral chemoreceptors only play a minor role in breathing, unless a patient is a chronic CO2 retainer (so the theory goes), of which we will discuss in a moment.

Thus, we will focus on the central chemo receptors for purposes of simplicity.

Let me confuse you a minute. The real drive of breathing is actually hydrogen ions . As hydrogen ions increase, your breathing speeds up. But, since hydrogen ions are not allowed to cross the blood brain barrier so that the pH of the brain can be different from the pH of the body, it cannot directly be used to stimulate breathing.

Thus, CO2 is used. CO2 is allowed to cross the blood brain barrier. Excess levels of CO2 arrive in the brain and are received by the Central Chemo receptors. Thus, "elevations in CO2... cause rapid diffusion of the gas into the CSF (Cerebral Spinal Fluid), where it dissociates into hydrogen ions and lowers the CSF, thereby stimulating the central chemo receptors. The central chemo receptors, in turn, signal the medulary centers to increase ventilation."

So you can see, CO2 "indirectly" causes changes in respiration's.

If the CO2 becomes chronic, or is still hanging at a high level after a day or two, according to Egan, the stimulatory effect of the high CO2 diminishes because the kidneys will try to compensate for the high CO2 by creating more buffers (bicarbonate or HCO3), thus causing the pH of the CSF to go back to normal. The medulla thus receives a signal that CO2 is normal, even though it is actually elevated.

It therefore is easy to tell which patients are chronic retainers because their HCO3 level will usually be high, and usually something greater than 30.

And, in Chronic COPD patients, this CO2 level may stay high while at the same time maintaining homeostasis (a normal pH), and, thus, CO2 has less of an effect on breathing as it would on a normal person (in theory anyway).

In effect, it may be normal for a COPD patient to have a CO2 of 50, and a PO2 of 50. We call these guys members of the 50/50 club, or chronic CO2 retainers or simply chronic retainers.

Changes in PO2 have no direct effect on Central Chemo receptors.

As anything in life, this process is far more complicated than I just explained, but you can see from what I have described here why in many COPD patients CO2 may lose its ability to stimulate a person's drive to breath, especially when CO2 is chronically elevated (or so the theory will have it).

And this is where the gold standard of RT comes into play. As, when a patient has a chronically elevated CO2, it is believed that it stops being the drive to breath. In these patients, it is believed that oxygen becomes their main drive to breath.

Thus, we must take a look at peripheral chemo receptors. According to Egan, "Peripheral chemo receptors are not very sensitive to CO2 changes... their primary role appears to be in response to hypoxia."

Normal PO2 is 104. It does not effect the peripheral chemo receptors until it is less than 60. To put this in perspective, a PO2 of 60 will usually generate a sat (SPO2) of about 90%. As the PO2 falls from 60 to 30 torr (SPo2 of 90% to 60%), the rate of breathing should be expected to be increased due to signals sent from the peripheral chemo receptors.

Now, as we've explained, CO2 is normally the drive to breath. But, if a patient with COPD is having so much trouble breathing that there is no way possible that he can speed up his breathing further to blow off that excess CO2 "regardless of patient effort," CO2 no longer is the drive to breathe, and PO2 becomes the drive to breathe.

This is called the hypoxic drive theory.

And this, my fellow readers, is why doctors soooooo do not want to put a COPD patient on more than 2LPM even though their oxygen levels continue to be low.

This is why many COPD patients are allowed by many doctors to have sats in the mid to low 80s even though low levels of oxygen may be deadly to the heart. This is why many doctors refuse to put many COPD patients on 100% oxygen, because they are afraid they will knock out their drive to breath. They are afraid the patient will become lethargic and die.

The hypoxic drive theory is the gold standard of respiratory therapy, but is it a fallacy or a reality? This is a debate that may be ending.

(To view part three click here. To return to part one click here.)

"I'm not sorry I have COPD," she said

"You don't know what it's like to sleep in these beds," Mrs. Patient said, and smiled. It was the first time I had seen her smile in the two days I had taken care of her.

"You might be surprised," I said, preparing my syringe to draw my a.m. ABG.

"How could you possibly know what it's like to sleep on these uncomfortable mattresses?" She was admitted with exacerbation of COPD, and had been requiring a bronchodilator at least every two hours until today. She was looking pretty comfortable all slouched down there on the bed.

"You might be surprised. "I grabbed her hand, knelt alongside her and held her hand, feeling for her pulse.

"Usually they get it on the other hand. They keep missing on that one."

" I feel a great pulse here." I uncapped the syringe.

"Okay, I'm ready." I'm not poking you yet. I'll warn you when I'm ready."

She relaxed and smiled again. "So what did you mean I might be surprised."

"Because I slept in this very bed in December. I know how uncomfortable it is first hand." The needle pierced the skin. She did not flinch.

"You did, really?"

As she pondered that, I watched as the blood flowed quickly and smoothly into the syringe. I pulled out the needle and held her wrist with a pad of white gauze. "Yeah. I know exactly what these beds are like."

"What was wrong with you."

"A bleeding ulcer."

"How bad was it that you had to be admitted?"

"I lost four units."

"Oh, I guess that's bad. How does a young man like you get an ulcer?"

"It was probably secondary to asthma medications, I guess. Or a bacteria. No one really knows for sure."

"Oh, you have asthma."

"Yeah, I've spent my fair share of time in hospitals for it, but not in the last ten years." I removed the gauze. She was still bleeding a little. I held pressure again.

"Oh, I'm sorry."

"I'm not. I wouldn't have this job, and I wouldn't have my wife, and I certainly wouldn't enjoy writing if I didn't have asthma."

"That's a good attitude. You know what, I'm not either. I mean, about my COPD. I'm not sorry I have COPD." She smiled. "There's people who have it a lot worse than I do."

I didn't say anything to that for a few minutes. I thought of the irony of that statement. Here she was knowing she may never breath normal again, and probably will spend the rest of her life thinking about every breath, and she says she doesn't feel sorry for herself, that there are people far worse than her.

Finally I broke the silence. "I love that attitude in a patient."

She smiled. "You didn't get bad lungs because you smoked, right?"

"That's correct." I plastered a bandage over the gauze and stuck it on tight. "All done."

"That didn't even hurt at all," she said, looking down at her wrist.

"Thanks."

I grabbed the capped syringe and got up to go. She said, "I made myself this way. I destroyed my own lungs."

"When did you start?"

"When I was 17. I quit for five years believe it or not, then I started up again and smoked for 40 years. How stupid was that?"

"To your defense, though, back when you started you probably didn't hear all the time how bad cigarettes were for you."

"On the contrary. You had doctors on commercials talking about how cool it was to smoke."

I chuckled. "On the other hand, kids today know of the dangers, and they still smoke. Most kids just think they'll live forever."

"True."

"You probably would have smoked regardless too, hey?"

She smiled. "You know what, you're probably right there."

I've have this type of discussion with a patient from time to time, almost to the point I know exactly what to say; what they want to hear; how far I can push them. Especially when I'm tired at five in the morning I'm not shy about sharing my experiences with my patients, and getting them to share their experiences.

Perhaps we both get some solace out of it.

"Is there anything I can get for you before I leave?"

"No," she said. "But you could take a picture of me as I lie here in this bed and send it to someone who's thinking about smoking. Maybe they'd think twice."

"I doubt they'd think twice,"I said, jokingly

"I doubt it too."

Cell phones as deadly as cigarettes???

Here is something to think about. We all know that the government got an entire generation of people addicted to cigarettes by 1917. They did this despite warnings way back then that smoking was deadly. Yes, they knew way back then the hazards of smoking, but they never said anything.

Check out this timeline of smoking, and you will see that the Fed might not have been completely honest with us.

For example, the "Federal Food and Drug Act of 1906 prohibits sale of adulterated foods and drugs, and mandates honest statement of contents on labels. Food and Drug Administration begins. Originally, nicotine is on the list of drugs; after tobacco industry lobbying efforts, nicotine is removed from the list."

Because of the fear that cigarettes are hazardous, and not wanting to be seen as a person who endorses the idea that children start smoking, Major League baseball player Honus Wagner insisted that his baseball card no longer be provided in cigarette packages. This ultimately resulted in his card being the most valueable care all time.

In 1912, the "first strong link (was) made between lung cancer and smoking. In a monograph, Dr. Isaac Adler is the first to strongly suggest that lung cancer is related to smoking." That was the same year many were concerned about the addictive quality of cigarettes.

Then, in 1914, Henry Ford and Thomas Edison talked about the dangerous effects of smoking cigarettes, and that Thomas Edison said it "has a violent action on the nerve centers, producing degeneration of the cells of the brain, which is quite rapid among boys. Unlike most narcotics, this degeneration is permanent and uncontrollable. I employ no person who smokes cigarettes."

Then, in 1917, an entire generation of young people comes home addicted to cigarettes. That was where the problem began.

The Fed never said anything because... why???

Here I have been telling my patients the past few years that people who have bad lungs now because of smoking didn't know any better in the 1950s when they started, and that today's kids do. Thus, today's kids have no excuse.

But, is it possible that kids back in the 1950s should have known better, and the government didn't say anything just because the cigarette industry was so good for the economy.

Cigarettes have been positively linked to various cancers, heart disease and COPD.

Now there have been theories and some vague studies the past few years that cell phones might also be linked to cancer. Do they know more than they are telling us? Should we be careful? Should we keep an open mind about this???

Or is this just poppycock?

In the days to come, we'll review this further.

Oh, and here's something in the timeline I found interesting. In 1920, " in Atlantic Monthly says, 'scientific truth' has found 'that the claims of those who inveigh aginst tobacco are wholy without foundation has been proved time and again by famous chemists, physicians, toxicologists, physiologists, and experts of every nation and clime."

Is it possible that cell phones will be the new cigarette? That cell phones are linked to brain tumors.

Johnny Cochran, O.J. Simpson's lawyer, was diagnosed and died of a brain tumor. It was widely known that he was on a cell phone all the time. And, while scientists don't know why smoking causes cancer, they just know that it is linked to lung cancer. The same can be said of cell phones and brain tumors. Or no???

Ear piece down to holster on belt is the industry recommended use of cell phones. If you dont' do this, will you increase your risk of brain cancer?

I don't know, I'm just as curious as you? Just something to think about.

Some basic facts about COPD you should know

Perhaps secondary to pneumonia, the second most common type of patients I see on my respiratory therapy treatment sheet are COPD patients. In fact, I've seen so many of these patients I can recognize them by mere sight.

COPD is going to be the focus of this blog for the next month or so. I'm going to be analyzing this disease to provide me and my fellow RTs a nice refresher course, but to better educate my COPD audience as well. The more we RTs know, the better we can benefit our patients, and the more our patients know, the greater likelihood they will avoid having to come in to see us RTs.

I always say when I'm leaving a room knowing that the patient is going to be discharged later that day, "Well, the next time I see you it will be at a grocery store or a restaurant." Then they laugh. And they laugh with me two weeks later when I actually do meet them in a restaurant and barely recognize them because they are wearing street clothes.

But, far too often, we meet again in one of our hospital suites. Sometimes it's only a week or two after they were discharged, and the lucky ones I don't see for another year or so. Either way, the more they know, and the more I know to educate them with, the better off they are, and the more likelihood they can avoid visiting me again.

However, aside from being well educated, they also have to be compliant, or else no amount of education will do any good.

You can look up the definition of COPD via the various links on this blog if you want to. I'm not going to go into detail on that, at least not yet. What I'm going to delve into is deeper than what will be covered on most COPD websites.

I've decided that this week I would simply relay some basic facts regarding COPD that I've obtained via various sources:

1. COPD is the 4th leading cause of death worldwide, yet 75% of those affected remain untreated. It is also the 4th leading cause of death in the U.S.
2. The World Health Organisation estimates 600 million people worldwide have COPD.


3. COPD is projected to be the third leading cause of death by 2020 with only heart disease and cerebrovascular disease accounting for more deaths.


4. Higher prevalence rates for COPD are found in men than in women globally reflecting historic gender differences in smoking behaviour.


5. Prevalence figures for COPD are believed to be underestimated. Sufferers tend not to seek medical advice until the disease has progressed and the condition is severe. Or, in other words, an estimated 30 million Americans have COPD, while only 16 million adult Americans have been diagnosed with disease.[


6. Quality of life is severely affected in patients with COPD, with 80% of patients hospitalised following an exacerbation reporting a health status rated or quoted by a physician as being 'worse than death'.


7. Lost productivity due to COPD can have a devastating effect on the economy, and the greatest emphasis of medical professionals is to improve the quality of life for COPD patients so they can be productive members of society.


8. COPD has a higher mortality rate than asthma (5,438 deaths from asthma in 1998 versus 107,000 deaths from COPD in 1998).)


9. The highest increase in mortality has been in white women, as observed between 1960 and 1998.


10. In 2000, the annual cost to the nation for COPD was estimated to be approximately $30.4 billion. Health care expenditures accounted for $14.7 billion, and indirect costs (decreased income due to loss of work or premature death) were $15.7 billion.


11. In a recent survey, 7 out of 10 smokers could not identify COPD as a top-five killer.


12. In 2002, about 125,000 people died of COPD.


13. While other chronic health diseases such as heart disease and diabetes have decreased in the past 20 years, COPD rates have steadily increased.


14. In a recent survey 66% of Americans did not know that COPD kills more women than men.


15. Women who smoke are more susceptible to developing COPD than are men.


16. Women may develop COPD at an earlier age and with less duration or intensity of smoking


17. U.S. women had more COPD hospitalizations (404,000) than men (322,000) and also had more emergency department visits (898,000) than men (551,000) in 2000.


18. More women than men die of COPD.


19. Cigarette smoking is the leading cause of COPD


20. Breathing in second hand smoke can cause COPD (in fact, I witnessed this with my grandma.)


21. Working around certain kinds of chemicals and breathing in the fumes for many years can cause COPD.


22. Working in a dusty area for many years, air pollution can cause COPD


23. Having a history of frequent childhood lung infections can cause COPD


24. Alpha 1 Antitrypsin Deficiency can cause COPD

Next week I'll focus on ways COPD sufferers can avoid a trip to the ER and live a more productive life. I'll provide some real life examples form my experiences.

Resources: AARP, COPD Coalition, yourlunghealth.org,

Pneumonia: Here's how you can prevent it

As I wrote in yesterdays post, over 3 million people are diagnosed with pneumonia each year, 500,000 require admission to the hospital.

A question I get often from my patients is: "What can I do to prevent myself from getting pneumonia?"

To get a good overall idea of what pneumonia is, and who exactly is at risk, you should check out the post I wrote yesterday, which I will link to here.

Every person, particularly the elderly (over age 65) and/or chronically ill, should keep pneumonia in the back of their mind, because chances are they are at a high risk of getting it. There are a few simple things you guys can do to reduce the risk of getting pneumonia.

Keep in mind, however, that there are no guarantees.

The simplest thing you can do is wash your hands. There is no more effective thing you can do to prevent the transfer of viruses and bacterias than by simply washing your hands often.

Another simple thing you can do is get the pneumonia vaccine offered to you by your doctor. Currently, there are vaccines available for pneumonias caused by pneumococcal pneumonia, Haemophilus influenzae, and influenza virus.

Respiratory-lung-healthcare.net reports that the vaccines are about 80% effective in young adults, but not so effective in those who are at high risk. Likewise, not all pneumonias have a vaccine. Needless to say, that's no revelation there. Many patients who have been diagnosed with pneumonia also say they received the vaccine.

Thus, we obviously cannot rely just on the vaccine to prevent pneumonia.

So, besides vaccines, the best therapies to prevent pneumonia is cough and deep breathing exercises (with a good 3-6 second breath hold), and exercise, even a simple walk around the room can be effective enough to prevent pneumonia.

At our hospital, doctors order all patients at high risk for pneumonia to be provided and instructed on the use of an Incentive Spirometer (IS). It is their belief that any patient can do an IS, and that it's equally effective in preventing pneumonia in all patients. However, that is not always the case in the ideal world.

That in mind, here is the long version of what I tell my patients:

"Many years ago pneumonia was very prevalent in hospitals. Many post-op patients were getting pneumonia, and many of them were dying. Familiar with these statistics, some wise person decided that they were developing pneumonia because they weren't taking in deep breaths.

"Normal healthy people take in three or four sighs every hour. This is the bodies natural mechanism for exercising the parts of the lungs that are not used during normal respiration's.

"However, when you become debilitated in one way or another, you are elderly, weak, sore from breaking your ribs, sore because you had surgery on your chest or abdomen and don't want to take in a deep breath, you have Lou Gehrig's disease, are paralyzed, or something else that diminishes your ability to move or take deep breaths, then you are susceptible to getting pneumonia.

"What you need to do is to concentrate on your breathing, something most people take for granted. While you are home, after eating breakfast, you should concentrate on taking deep breaths. In fact, you should do this once every hour or two. And then you should force yourself to cough.

"You take in a slow deep breath through your nose, hold your breath for three to five seconds, and then you exhale slowly. You should do this five to ten times, and then cough. This whole process helps you to recruit and fill with air any collapsed alveoli that are susceptible to pneumonia, expectorate secretions, and exercise your lungs.

"In the hospital, we encourage those at high risk for pneumonia to not only do this, but we use what we call an incentive spirometer. But, in essence, an incentive spirometer is no more effective for preventing pneumonia than a good cough and deep breathing session with breath hold."

Of course, here is where I show them how to use the IS. Most patients do well with the IS, however, some patients just can't seem to get the hang of it. For these patients, I revert them back to the simple cough and deep breathing exercises.

I have never found a patient not be able to do effective cough and deep breathing exercises, even most dementia and Alzheimer's patients do well with this.

Some RTs and RN, in my humble opinion, get so wrapped up in the idea that the IS must be used to prevent pneumonia, that they focus all their energy on having the patient use it, even though the patient is not using it correctly, or, more than likely, is simply unable to comprehend how to use it.

On these patients, I say, "Forget the IS."

This is just something to keep in mind.

Now, our RT bosses might be mad at me for telling you how to prevent pneumonia, because they want you to get sick so they can make money off you, but not me; I want you guys to be educated on the best means of avoiding the need for our services.

The other thing to keep in mind is that your body is not used to being immobile. If you're not moving around, you open the door for a variety of complications, pneumonia being one of them.

This is why, even after you have a major abdominal or chest surgery, your nurse will have you walking the halls, regardless of your level of pain. You might get some good drugs to help with the pain, such as Morphine, but doing this may still be a challenge.

We here at the RT Cave, when teaching the IS or cough and deep breathing exercisers, encourage our patients to push themselves to that pain threshold. It may be agonizing now, but it will allow you to get out of the hospital quicker, which will not be the case if you get pneumonia.

Immobile hospital patients will be taken care of by qualified RTs and RNs who know the best techniques of preventing pneumonia. For people living at home who are at high risk, it's your job to educate yourself, and that's the purpose of this post.

If you want an incentive spirometer, you'll have to refer to your doctor. If you want to know how to use an incentive spirometer, click here. For a boring but effective video on how to use an IS, click here.

Still, nothing is more effective than simple cough and deep breathing and breath hold exercises to eliminate your odds of getting pneumonia. You healthy people don't have to think about your breathing, but anyone at high risk must and should.

That concludes today's class.

Singulair: Another asthma miracle drug

This is my weekly focus on patient education, where I will discuss everything you need to know about (fill in blank).

The theory here is that, as a patient, I think it's good to go to your doctor armed with as much knowledge as possible. I call these posts patient wisdom, and you can refer to them at your convenience by clicking on the patient wisdom link near the top of this blog.

Today's focus is on allergies, asthma and Singulair.

I talked to one of the doctors I respect very much a few months back while I was working, and somehow the topic of discussion changed to me, and how much I love spring, but hate how miserable my allergies are at that time of year.

He said, "I think that every asthmatic should be on Singulair. I prescribe it for all my asthma patients."

So, when I went to my doctor, I said, "So, what would you recommend for allergies?"

My doctor said, "Well, did you try over the counter stuff, like Drixorol, Claratin, benadryl and that type of stuff?"

"Yeah, I've tried it all over the past 25 years, I even had allergy shots as a kid. None of it seemed to work. I was just wondering if you knew of anything stronger I might try, not that I really want more medicine to take or anything."

"Well, there is Singulair."

"Ah, that's what I was leading at. I didn't want to say Singulair just in case you had a better idea."

"Yeah, I suppose we could try that."

There, I got what I wanted. "Since spring is right around the corner, I will know right away if it works."

So, how do you know if Singulair is right for you?

Pretty much, based on my research, Singulair has proven effective for anyone with Allergic Rhinitis (hay fever) and asthma/allergies. For the most part, these two tend to go hand in hand.

Thus, if doctors could somehow prevent allergies, they could control asthma.

Finally, in 1998, after spending millions of dollars and 63 years studying leukotrines and working on a way to block their release, Singulair was approved for use by the FDA.

Singulair has an active ingredient in it called Montelukast sodium, which blocks the action of leukotrien, thus preventing allergies, and preventing bronchospasm caused by allergies, and, in turn, preventing asthma.

So lets back up a bit. What the heck are Leukotrienes? Better yet, what causes allergies in the first place?

When our bodies sense a foreign substance that might cause harm has entered the body, such as a bacteria or virus, it releases chemicals to attack the foreign substance. This is the bodies normal immunologic response to prevent and fight diseases. This is a good response by our immune system.

However, in some people, those of us who are prone to allergies, our immune system responds to harmful things, but also things that are relatively harmless, and generally cause no reaction in people who do not have allergies. In essence, with allergies, our body is fighting itself, and this is bad.

These harmless things that cause allergies are called allergens. Some common allergens are pollens released from trees, mold, hay, grass, dander, and food.

For the most part, if something causes us to have an allergic response, or asthma, we try to identify our triggers, in this case allergens, and avoid them. If you only have one allergen it might be easy to avoid, but for us asthmatics who are allergic to a ton of things, the only way to avoid all of them is to live in a bubble.

Now we all know that's not possible, or at least extremely difficult.

To give you an idea of the allergy process, I'll provide here a pithy example.

Say you are prone to allergies and breathe in a molecule of pollen. Your body fails to recognize it as harmless, and releases a chemical called pollen IgE antibody that binds to mast cells.

Now, at this point, nothing really happens, but the next time you are exposed to pollen, the IgE primed mast cell releases chemical mediators which attach to specific cells in the body causing inflammation.

Leukotreins are one type of chemical mediator which is responsible for inflammation, and are the culprits responsible for causing bronchoconstriction (tightening of the muscles around the airways) and swelling of the airways.

Thus, if we could find a way to block the release of these leukotriens, we could stop, or greatly diminish, an allergy attack, and thus an asthma attack.

And that's where Singulair comes into play. It blocks the release of leukotreins.

It has been proven effective for the management of allergies in asthma, and allergic rhinitis. It usually takes 3-7 days to start working, so, unlike antihistamines, it does not have an immediate effect, and must be taken on a regular basis (every day) to be effective.

In other words, even if you have no symptoms, you should never stop taking this medicine, unless otherwise prescribed by your doctor.

Singulair has not been proven effective as treatment of itchy eyes, itchy nose, sneezing and runny nose. If these symptoms continue to be problems for you, you might want to try an antihistamine, which can be purchased over the counter.

There is one other use for Singulair, and that is for people who have excercise induced asthma.

According to Health Library at CNN.com, "Because exercise-induced asthma has the same symptoms and results from the same airway reaction involved in regular asthma, standard asthma medications can control it."

Patients who experience excercise induced asthma but don't necessarily have a problem with allergins, and do not already take the medicine on a daily basis can take the medicine two hours prior to excersising, but not again for 24 hours thereafter.

Some patients have managed to control their asthma, excersise induced asthma and/or allergic rhinitis with the use of Singulair alone. However, some asthmatics may need other prophylactic therapies, such as Chromolyn or Advair and an occasional use of a rescue medicine such as an Albuterol inhaler.

So there, in a nutshell, is everything you need to know about asthma related allergies and singulair.

For more information, check out this link. Also check out this, the official website of singulair

That concludes today's class.