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

Popular Heartburn Drugs Linked To Dementia

These overprescribed drugs have been linked to dementia.

The link between asthma and GERD and heartburn has been known for quite some time now. There's also a known link between COPD and the stomach. Many of these patients find themselves taking a daily dose of proton pump inhibitors such as Prilosec, Nexium, and Prevacid.

However, a new study suggests that these drugs may cause dementia, with the risk increasing with age. Those over the age of 75 who take these medicines have a 40% increased risk for developing dementia compared to those who do not take them. That's a pretty significant risk, enough so that some doctors are now sharing this information with their patients, giving them the choice whether or not to continue using them. 

Interestingly, another type of antacid, H2 blockers, have also been linked with dementia. These include medicines like Tagamet, Pepcid and Zantac. 

Researchers are not sure why these popular stomach acid reducers might lead to dementia. One theory suggests that they may cross the blood brain barrier and affect brain enzymes. They may impact the gene that encodes the protein beta amyloid, causing increased beta amyloid levels in the brain. 

Beta amyloid has already been shown to builds up in the brains of people with Alzheimer's Disease, and is a biomarker for predicting who will get that disease. They believe that when in abundance, it may destroy synapses before forming plaques that cause nerve cells to die. 

However, what is known is that up to 75% of patients currently prescribed them do not even need them, and 25% of these patients could probably stop taking them without facing any consequences. 

This is another one of those situations where the potential risks must be weighed against the potential benefits. If you stop taking them and experience worsening stomach trouble, then you should probably continue taking it. However, if you stop and feel fine, then you probably could do fine without them.

As usual, do not stop taking any medicine without first consulting with your doctor. 

Further reading and references:

1. CBS News: Popular Heartburn Drugs Linked To Dementia
2. rxlist.com: Proton Pump Inhibitors Linked To Dementia
3. WebMD: Beta Amyloid May Identify Alzheimer's Disease
4. Stanford Medicine: Scientists Reveal How Beta Amyloid May Cause Alzheimer's

Study links rescue inhaler overuse to depression

A new research study reveals that "overuse of rescue inhaler in chronic asthmatics linked to depression." While the researchers were not conclusive on how to interpret these results, they seem to be leaning towards blame the asthmatic.

The study was conducted by the University of Arizona and involved 416 patients.  The results were as follows:

• About half of all participants used albuterol as expected, while 27 percent of participants overused albuterol and 22 percent underused albuterol.
• 45 percent of over-users used albuterol on a daily basis.
• Participants across the board used albuterol on symptom-free days about 20 percent of the time.
• Eighty-eight percent of daily users were over-users of albuterol.
• Over-users had more days in which they had symptoms and scored worse on the asthma control questionnaire, the shortness of breath questionnaire and the asthma symptom utility index.
• Over-users of albuterol had worse mental functioning when compared to expected users of albuterol.

So that was the first part of the study.  The participants were also studied to see how they scored on a depression test, with the following results. 

• 19% of those who underused albuterol had a depression score of 16 or more
• 17% of those who used albuterol as expected had a depression score of 16 or more
• 32% of those who used albuterol too much had a depression score of 16 or more

Researchers who interpret studies concluded the following: 

What isn’t clear is whether depression leads to worsened asthma symptoms and an increase in albuterol use or whether albuterol use contributes to the development of depression. Asthma has a significant relationship with one’s mental status, and emotional states like anxiety can contribute to asthma exacerbations, leading to the need for a rescue inhaler.

It also isn’t clear whether or not albuterol over-users were more or less compliant with the chronic medications asthmatics take on a regular basis in order to avoid exacerbations of their disease process. If this is the case, doctors need to educate patients — depressed or not — on the use of chronic asthma medications so rescue inhalers like albuterol are less necessary.

My problem with these results is this: Why do they always blame the asthmatic?  If I don't have good asthma control, it's because I don't take my asthma controller medicines.  Plus, how do you define albuterol overuse? I mean, I know they define it as using it more frequently than a doctor prescribes for, but how do they know the doctor is right.

Let me put it this way, many recent studies have confirmed that corticosteroids, a top line medicine used to reduce inflammation in asthmatic lungs to make them less sensitive to asthma triggers, does not work on those with severe asthma. Inhaled corticosteroids do not help those with severe asthma gain good asthma control.  So these patients, by default, will need to use their rescue medicine more frequently.

Likewise, most asthmatics do not have pure asthma, or asthma by itself.  Like myself, most asthmatics have something else with it, like allergies.  Actually, studies show that 75% of asthmatics also have allergies, and this is a double whammy.  My point here is that, even if you have good control, you can still have trouble breathing on a regular basis.  You may still need to use your rescue inhaler daily.

Yes, if you have pure asthma you shouldn't need your rescue inhaler more than 2-3 times in a 2 week period. There are many asthmatics who would fall into this category.  Still, there are likewise many asthmatics who do not qualify for this method of defining control because they do not have pure asthma.

I describe what real asthma control is in my post"What is good asthma control?"  I wrote:

The National Heart Lung and Blood Institutes (NHLBI) Asthma Guidelines define control pretty much the same as the GINA guidelines: Control is the degree the above guidelines are met plus the degree YOUR goals of therapy are met.

Your goals may be:

• I just want to be able to walk
• I want to be able to exercise
• I don't want to miss any more school or work due to my asthma

Another means to monitor control is your own personal satisfaction. Are you satisfied with your life given your asthma severity?

Plus this notion of monitoring control by how often you use your rescue inhaler doesn't work if you don't have pure asthma.  For instance, my current doctor ordered my rescue inhaler to be used four times a day. Well, how does he know when I'm going to be short of breath?  Sometimes I go weeks without using it. Other times, such as right now when I have a cold, I use it several times a day.

My point here is that you need to be careful when reading the results of research like this.  You have to take what you read, even in peer reviewed journals, with a grain of salt. While the studies themselves come to accurate conclusions, the people who interpret the results sometimes get it wrong.  They get it wrong because they do not have asthma so they don't know what it's like.

Further reading:

• Eureka Alert: Study: Severe asthma fails to respond to mainstay treatment
• Hardluck Asthma: What's it like to have asthma?
• NHLBI: Asthma Guidelines
• RT Magazine: overuse of rescue inhaler in chronic asthmatics linked to depression
• Lung Disease News: Overuse of rescue inhalers in asthmatics linked to depression
• Healthcentral: What is good asthma control?
• Healthcentral: How to obtain good control of your asthma?

Medicine based on consensus, not science

Medicine is an art based on science.  Much of medicine is based on flawed science. Or, as Richard Feynman once said, science is the belief in the ignorance of experts. 

Much of science is not even science: it's consensus.  It's basically the world's leading experts voting on what they think is fact, rather than waiting for the evidence to reveal the truth.  It's creating theories and voting on which ones should be in the forefront of our minds.  So when deciding on what to believe, we must never forget that "science is about evidence, not consensus."  

It is so hard in the medical profession to separate consensus from science.  In fact, one of the things that fascinated me most about the medical profession is it's loose relationship with science.  In fact, early on in my studies I learned that medicine is loosely based on science, and more so based on consensus, which is not science at all. 

Look at the hypoxic drive theory.  It was based on a study of four COPD patients, and became a gold standard based on a presentation by EJM Campbell to pulmonologists in 1960 about the results of a study based on only four COPD patients.  So basically the hypoxic drive theory, or hoax as I like to call it, was based on a consensus of experts, and had nothing to do with science. 

So basically physician's under oxygenated their patients for over 70 years, and many still do, based on a consensus.

Look at all the breathing treatments we give based on a consensus that albuterol cures every lung ailment you can think of. Our new healthcare law insists that a lung patient must be sick enough to need 3 breathing treatments for reimbursement criteria to be met. This includes COPD, CHF, Asthma, Pneumonia, etc. So 3 breathing treatments are ordered on all these patients, and it's assumed they are needed. What's wrong with this picture? It certainly has nothing to do with science. 

Other examples of consensus over science include:

• BiPAP pushes fluid out of lungs
• The earth is flat
• Man made global warming
• The continents cannot drift
• Stress causes ulcers
• Asthma is one of the seven pychosomatic disorders
• Phlogiston was necessary for combustion to take place

All of these theories are, or were, so widespread, and so well accepted, that they caused people to focus on treatments and therapies that probably did more harm than good (like under oxygenating COPD patients). As in the case with asthma, consensus caused experts to focus so much on a dead end path that it prevented the advancement of knowledge to the detriment of those who suffered from it (i.e., experts focused on treating asthma with psychosomatic medicines when they should have been looking treatments for inflammation and bronchospasm). 

So when you're thinking about whether or not you want to believe something is true, consider the evidence and not the consensus.  The fact that a majority of people believe something to be true does not make it so. In other words, it's okay to oppose the majority opinion, so long as the evidence is on your side. 

When a doctor orders something, it's your job as a therapist, or a nurse, to do as you are instructed.  For instance, if a doctor orders you to give a breathing treatment, then you must give it regardless that you know it is a waste of time.  As the old saying goes, "It can't hurt." 

Still, it really does hurt, because you're putting medicine into someone that doesn't need to be there, and, even though we can't always see them, all medicines come with side effects.  And then there's also the side effect of second hand ventolin on those who are doling it out all day long.

However, when a doctor orders for you to maintain an SpO2 in the low 80s because of the hypoxic drive myth, it's time to rise up and challenge the consensus for the benefit of the patient, because, Lord knows, oxygen is beneficial to the living heart. Thankfully the hypoxic drive consensus/hoax is slowly fading, and COPD patients are actually being oxygenated these days. 

Further reading.

• Rush Limbaugh: Peer Reviewed Science Exposed as Fraud
• NY TIMES:  Many Psychology Findings Not As Strong As Claimed, Study Says
• Wall Street Journal: Science is About Evidence, Not Consensus
• RT Cave: Second Hand Albuterol

Studies conclude: Atrovent can't hurt

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

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

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

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

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

They concluded:

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

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

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

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

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

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

So what are your thoughts?

References:

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

Do inhaled corticosteroids reduce COPD exacerbations?

There has been an increase in the number of physicians ordering inhaled corticosteroids for patients suffering with pneumonia and chronic obstructive pulmonary disease.  So, is there any evidence to support this treatment regime.

Let's review the evidence:

1.  Norton JL et al notes that the use of inhaled steroids is among the most common treatment for pneumonia.  However, they also reduce the immune response and, therefore, slightly increase the risk of being diagnosed with pneumonia.

2.  An article in the April 15, 2011, issue of American Thoracic Society's Journal of Respiratory and Clinical Critical Care Medicine, reported on a review of clinical studies, which concluded that inhaled corticosteroids help to reduce mortality compared to those who were not taking inhaled corticosteroids. They concluded inhaled steroids reduce exacerbations by reducing the underlying inflammation in the air passages. However, while it decreases exacerbations, it also increases the risk for catching pneumonia.  Those using inhaled steroids had a 30 day mortality rate of 10%, and those not using it had a 13.6% mortality rate. The 90 day mortality rate was 17.3% for those who used ICS, and 22.8 for those not using ICS.

3.  Ritesh Agarwal et al studied the effects of ICS on COPD patients and concluded: "There is only a modest benefit of ICS in preventing COPD exacerbations, which is not related to the level of baseline lung function on metaregression analysis. The benefits of ICS in preventing COPD exacerbations thus seem to be overstated."

Conclusion:  There does seem to be evidence that inhaled corticosteroids reduce exacerbations of COPD.

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Benefits of NIV for COPD-CO2 retainers

Citing previous studies, Augusto Savi, et al lists the following as the advantages of using noninvasive ventilation for chronic obstructive pulmonary disease (COPD) patients presenting with respiratory distress. T

1. Increases tidal volume
2. Improves CO2 elimination
3. Reduces respiratory drive
4. Reduction in treatment failure
5. Lower mortality
6. Fewer complications
7. Lower intubation rate

However, they note the following:

In these patients CO2 elimination was increased but overall ventilation-perfusion mismatch is not changed during NIV.  A more important effect is the unloading of the respiratory muslces, which are often close to fatigue in severe episodes of respiratory failure.  

Furthermore, they note the following regarding the safety of oxygenating these patients:

Crossley et al concluded that CO2-retaining COPD patients following a period of mechanical ventilation with PaO2 in the normal range can safely receive supplemental oxygen without retaining CO2 or a depression of respiratory drive.  A new ventilation-perfusjion relationship is established during ventilation to normoxia, and is not altered by further increasing the FiO2.  Nevertheless, the safety of oxygen supplementation during NIV in CO2-retaining COPD patients is not clear.

So it is quite clear that NPPV greatly benefits COPD patients in respiratory distress, and, likewise, there are no harmful effects of oxygenating them as needed to prevent hypoxia.

References:

1. Savi, Augusto, et al, "Influence of FiO2 During Noninvasive Ventilation in Patients with COPD," Respiratory Care, March, 2014, Volume 59, Number 3, pages 383-387

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12-hour shifts work well, study says

Most respiratory departments staff for twelve hour shifts.  However, there are those who believe the end result of this is staff that are too tired, particularly at the end of the shift, resulting in too many errors.  Considering errors in healthcare may result in serious consequences, many hospitals are now shifting back toward eight hour shifts.

This was a subject that the Lincoln Police Department (LPD, of Lincoln, Nebraska, put to the test by performing a study.  Of a police force of 300 personnel, 37 officers and supervisors volunteered to work 12 hour shifts. Researchers went on to evaluate these workers on a basis of both their personal opinion and their performance.  

Two of the main concerns was fatigue at end of shift.  Getting enough sleep was a top priority, and the only time this became a concern was when a long shift turned into over time.  However, this concern was resolved.  As noted by the researchers: 

Supervisors played a key role in managing calls that came near the end of the shift, holding some and stabilizing others until fresh officers were available to work the call and complete reports. Officers were encouraged to manage their calls and to notify supervisors if a late call was likely to extend into overtime. The resentment that some officers might feel when someone appears to be ducking work was replaced with the realization that other officers would do the same for them at the end of the shift.

This is something that we respiratory therapists experience, and the solution was quite similar.  While we don't get a ton of overtime, there are times when doctor orders late in the shift were handed off to the oncoming shift.  However, most of us realize that we will be equally tired at the end of our shift, so as long as someone doesn't abuse this system, it usually doesn't cause resentment.

Upon interview, the majority of the people who participated in this study had positive opinions of 12 hour shifts.  However, it was noted that all of the participants willfully volunteered for it, so it would only make sense that they would support it.

While most people reported feeling tired at the end of the shift, 100% said they were fully capable of performing their duties.

At the same time, an evaluation of performance also had positive results.  During the period of the study, there were no disciplinary actions and no complaints related to the longer work shifts.  Productivity measures were also good, as the number of traffic tickets and and intelligence reports went unchanged.

In response to this, the researchers said:

Some officers reported a new enthusiasm for the job with the 12-hour shifts that had a measurably positive effect on their work output, but there was no evidence that satisfaction with the work schedule affected the total output of the team.

The researchers concluded the following

Officer perceptions of the 12-hour shift were extremely favorable. Two of the 37 officers reported that before implementation of the new schedule, they were actively looking for a career change. The 12-hour shifts provided the right balance in their lives and renewed their enthusiasm for police work. Job satisfaction and morale are extremely high with this group of employees. This reaction is not likely to be universal, however, as these participants had positive expectations going into the schedule change and bid into the schedule by choice. In the department as a whole, a significant number of employees have a negative view of the schedule, though the schedule has sparked growing interest and may be expanded within the department.

The employee survey also indicates that 12-hour shifts have a mitigating effect on the negative aspects of shift work. Officers report being more rested and ready to return to work after days off but also note there is little time for anything but work during their work days. A more scientific approach might provide more conclusive data, but the survey and employee comments suggest that in addition to being happier, 12-hour shift workers are probably healthier as well.

This is not much different to how most of the people I work with every day feel about 12 hour shifts.  Most people are tepid about working them, but once they begin they find that they have more time off, and therefore more time to spend with friends and family, and more time to catch up on sleep.

Furthermore, the researchers concluded:

Before implementation, the main concern was whether 12-hour shifts would have a negative impact on the quality of the service provided by the department. Objective data suggest that it does not. There was no negative fiscal impact, and a trend toward less sick leave use was noted.

Good managers always look for ways to improve employee job satisfaction that do not adversely affect the organization’s mission. For a significant number of police officers, 12-hour shifts have proven to be a dramatic improvement and a viable scheduling alternative

Bottom Line:  While this is just one study, it shows that 12 hour shifts improve satisfaction and result in similar, if not slightly improved, performance compared to those who work 8 hour shifts.  So, hospital administrators should not shy away from 12 hour shifts due to unwarranted fears of diminished satisfaction and performance.

Second hand sitting linked to heart disease and diabetes

There was a study out a while back that showed that if you were fat and smoked that you were better off losing weight before you quit smoking.  The reason was because the study showed being overweight was worse for you than smoking.

Dailymail.co.uk reported on a study that confirmed just that.  Going to work and sitting at a desk all day can be more dangerous than smoking. 

The Dailymail reports the research was conducted by the American College of Cardiology.  The study concluded that "prolonged sitting is linked to cardiac disease, obesity, diabetes, cancer and even death and could be just as dangerous, if not more so, than smoking."

It makes sense because diabetes, cancer cardiac disease and death are all secondary to obesity.  Other people can get those conditions, yet your risk is greatly increased if you are overweight.  A study doesn't really need to be done to prove that.  Yet it helps.

The researchers believe that the more you sit around the less your body does to fight off those diseases.  It's just like smoking increases your risk by inhaling chemicals. 

Another similar study showed that watching too much TV was linked with increased risk for heart disease and diabetes.  I really don't think we need to do a study to show these things.  It's common sense. 

Second hand smoke has been proven to be almost as dangerous as first hand smoke. So it probably won't be long before second hand sitting is proven to be as dangerous as first hand sitting. 

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