How do you know someone is a CO2 retainer

Every week I check my statcounter to see who's typing things into Google or Yahoo and being linked to my RT Cave blog. Assuming the queries were not answered, I provide in this spot each week my humble responses.And, hey, if the query is comical, it deserves a comical response. If it's serious, I treat it as serious. That in mind, here are this weeks queries:

1. how do you know someone is a co2 retainer: Their CO2 is elevated, the pH is normal and the HCO3 is elevated. An example gas on room air would be CO2 50, pH 7.40, HCO3 36, PO2 55. Usually the HCO3 will be in the 30s.

2. particle size of advair: For particles to impact in the bronchioles of the lungs the particle size has to be about 0.5 microns.

3. ink: We still need it occasionally when we write in the charts, and to take notes on our clipboards.

4. albuterol stunt growth: No! Albuterol does not stunt growth.

5. does albuterol contain alcohol: Some of the new HFA bronchodilators do contain ethonol. You'll have to check the package insert to see if your inhaler does. For more information check out #3 above.

6. too tight to hear a wheeze: Sometimes a patient's lungs are so tight you will not hear a wheeze. In fact, it is quite common that bronchospasm does not result in a wheeze in both COPD and asthma patients. I've written here before that I think most wheezes that are heard are not bronchospasm (you can read more here). The best indicators of bronchospasm in my opinion are diminished lung sounds and shortness of breath.

7. asthma go away: There is no cure for asthma. However, by working with you doctor to find the best combination of asthma medicines most asthmatics do manage to gain control of their asthma (check out this post). Be patient, however, because it may take time. You will also have to do your part by learning of and avoiding your asthma triggers, taking all your medicines exactly as prescribed (check out this post). This includes taking your asthma controller meds even when you feel well. It is also recommended you have an asthma action plan to help you decide what to do when you question yourself. Check out the links in this answer and you should be well on your way to better asthma control.

8. how success came about : How do you define success? Do you define it by how much money you make? How much love you get? How happy you are? How satisfied you are? I like to define success as satisfaction. Either way, there is only one way to achieve success and that is by using common sense and making a gallant effort to do your best at whatever you do.

10. deep breathing exercises prevent pneumonia for immobile patient: It can but there is no guarantee. What you have to realize is that healthy people sigh 3-4 times every hour, and the reason they do this is to stretch and exercise the parts of the lungs that are not used on a regular basis -- like the lung bases. This ultimately prevents the alveolar sacks from collapsing (atelectasis) and can also prevent pneumonia. It helps you to expectorate any secretions deep in your lungs, particularly in the bases of your lungs. Taking 4-10 deep breaths with a 3-10 second breath hold has been proven to prevent pneumonia.

If you disagree or agree with my opinion feel free to leave a comment below, as we are all entitled to an opinion. If you have further comments or questions, feel free to write it below or email me.

Will asthma eventually go away?

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

Question: Will underlying asthma go away?

My humble answer: Asthma a tendency to disappear for months or even years, but once you have asthma you have it forever. Some asthmatics never have symptoms, and some have symptoms all the time. But most asthmatics have occasional asthma symptoms. It is an old fallacy that asthma disappears as one grows older. Still, many child asthmatics see their asthma improve as their lungs grow bigger. Once you are diagnosed with asthma, you should continue to see your physician once a year, and continue to take the asthma controller meds he prescribes whether you are having symptoms or not. Some asthmatics will need to take controller meds all the time, and some asthmatics may eventually and successfully be weaned off their asthma meds.

Question: Should I be taking a second medication with Foradil? Likewise, if I'm on this new medicine, should I keep taking Atrovent?

(Note: Foradil is the brand name of the long acting bronchodilator Formeterol. Formeterol is one of the two medicines in Symbicort. Foradil is a similar medicine to Serevent.)

My humble answer: Great question. Asthma is now believed to be associated with chronic (always there) inflammation (swelling) of the air passages in your lungs. Therefore, most asthma experts now believe that asthma that is not controlled by other medicines should be controlled with inhaled corticosteroids. Likewise, most asthma experts also recommends (as well as the asthma guidelines) that if a medicine like Foradil is required to treat asthma, that an inhaled corticosteroid be used with it. Thus, Foradil alone does not treat the chronic inflammation. Therefore, I highly recommend you talk to your doctor about Symbicort. Check out the link and read about it. It has both Formoterol (which is what Foracort is) and Budesonide (an inhaled steroid) in it. Many asthmatics have had great success with this medicine.

Likewise, if you take Formoterol (or Symbicort) you will not need to take Atrovent unless your doctor requires it. Atrovent is no longer a top line medicine for the treatment of most asthma cases.

Peak Flow Meter Monitoring

Your peak flow meter is often considered THE primary tool for to monitor your asthma. Yet, while most asthmatics have one, few use it. And, those who do use it, few of them use it correctly. I know this because I work with asthmatics and I ask.

Read my recent post from myasthmacentral.com and learn all you need to know about peak flow meters:

Your Peak Flow Meter Is An Important Tool
by Rick Frea Wednesday, December 09, 2009, @MyAsthmaCentral.com

If you're an asthmatic, chances are you have a peak flow meter somewhere in your possession. Or, if you don't, you might want to consider requesting one from your asthma doctor. A peak flow meter is one of the best tools ever invented for helping us asthmatics monitor our asthma at home.

The problem with peak flow meters is most asthmatics don't use them, or when they do they use them improperly. When I see these asthmatics in the ER, it's my job to educate them.

So, what is a peak flow meter? Why were you given one? How should it be used? Why do asthma experts think they are so important?

The U.S. Department of Health and Human Services (HHS) recommends in their asthma guidelines that every asthmatic work with his or her doctor to create an asthma action plan. This is a plan that helps you decide when to use your rescue medicine (like Albuterol), when to call your doctor, and when to have someone take you to the emergency room.

To help you decide what to do, the asthma guidelines recommend you either monitor your asthma symptoms, use your peak flow meter, or both. What you do depends on you, your asthma and your doctor. I wrote about asthma action plans here, and monitoring asthma signs and symptoms here, so in this post we'll tackle the importance of peak flow monitoring.

When I was a kid with hardluck asthma, my peak flow meter came in handy quite a few times. I say this because I was short of breath so often that I basically became tolerant to it. So, I had to use my peak flow meter as a tool to help me decide what to do.

As an adult my peak flow meter became less useful. It seems that whether my asthma is acting up or not, my peak flow values neither increase nor decrease. This is something unique to me. Still, I monitor my peak flows daily because you never know when it will come in handy.

The asthma guidelines recommend the following asthmatics use peak flow meters:

Moderate asthmatics: They are at increased risk over mild asthmatics

• Severe asthmatics: They are at highest risk exacerbations
• History: Patients who have a history of severe exacerbations
• Dyspnea intolerant: They poorly perceive airflow obstruction and worsening asthma
• Children: They have a harder time communicating how they feel, and this provides a good tool for parents to monitor their child's asthma.
• Personal preference: Some asthmatics prefer this method
• Doctor preference: Doctors can use this as a monitoring tool

A peak flow meter is a handy, easy-to-use, hand-held device that you blow into as hard as you can. It basically measures your peak expiratory flow rate (PEFR), or how much air you can blow out with maximum exhalation.

Because measurement of PEFR is dependent on your effort and technique, it's important you work with your doctor, nurse or respiratory therapist to make sure you are using it properly. To review proper peak flow technique, click

here.

Ideally, you can use your peak flow meter as part of your asthma action plan. According to National Jewish Health, the plan would work like this:

1. You blow into your peak flow meter every day for two weeks when you are feeling well. Whatever PEFR was your best, that one is considered your personal best.

2. You use your daily PEFR readings, along with your personal best, to help you decide what to do:

1. If your peak flow is less than 80% of your personal best, you take your rescue medication, then wait 20 to 30 minutes and check your peak flow again.

• 1 If your peak flow is not back above 80%, report this to your doctor.
• If your peak flow is back above 80%, re-check your peak flow about every 4 hours for a day or so. Call your doctor if you continue to need rescue medicine

2. If your peak flow is less than 60% consider this an emergency: Take your rescue medicine, and call your doctor or go to the emergency room right away.

It's really quite simple.

You should blow into your peak flow meter every day in the morning, and in the evening. This is important, because your peak flows may be normally lower in the morning. Then, if you notice your peak flows trending down, you can use this as an

early sign of an impending asthma attack, and you can act now to nip it in the bud.

Likewise, if you do need to make a visit to the ER or doctor's office, your doctor can use your personal best as an indicator of how well you are doing, whether you need another breathing treatment, or if you need to be admitted. This can save you a lot of time, and maybe even prevent you from needing to be admitted.

Also, your doctor can use your peak flow readings to monitor how well your treatment regimen is working, and as a "quantitative measurement" of how good or bad your asthma is doing.

So, even when you're feeling well, use your peak flow meter. Get it out of the box, out of the closet, dust it off, and place it next to your bed near your asthma diary to record the results. Then use it daily like the gallant asthmatic we're sure you are.

Note: The Asthma guidelines recommend all asthmatics either use symptoms monitoring or peak flow monitoring as part of their asthma action plan, or both. The guidelines note that both methods are equally effective.

A job well done is a job well done

Recently a code blue rang out over head, and the destination was OB. I swear I ran all the way from the RT Cave to OB in less than 15 seconds. And, yes, the adrenaline was flowing through my veins and I was even a bit shaky. I'm sorry, but even after 12 years on the job, this was the first time my neonatal resuscitation skills were needed.

I took over ventilations as soon as I got there while someone else did CPR. The doctor from ER showed up and immediately intubated the baby. He already had an umbilical art line in, so we we drew a gas and sent it to lab. Epi was given again and again and again. The heart came back, and then it faded, and then it came back and then it faded.

And while we held up strongly during the event, as soon as it was called several hours later the doctor slumped over the patient and said a long prayer. The rest of us stood by in utter disbelief that we had to whiteness this; in utter disbelief of what we had to do here at our small town hospital.

We prepare for this throughout the year hoping to never use these skills. We have to do special training to remind ourselves how to use these skills because we aren't a large hospital and we don't do this stuff on a regular basis. As I wrote above, this was my first in 12 years. And, except for the doctor and one nurse, it was the first neonatal code blue for all the rest of us.

Later I sat down to talk to the ER doctor who came up to help us. He said something along these lines, "When I arrived there you were bagging, another nurse was doing CPR, and every body else was just standing around. I think that you guys ought to be trained to do things better."

My jaw dropped. How could he say such a thing. Then my jaw dropped even lower when he said, "I hate having to go up to the floor at this hospital. Here I'm an ER doctor, and I have to go up and have my name put on a chart of a patient upstairs, so if there's a lawsuit my name is going to be in it."

How can you be so selfish? Is all I could think to say. Still riding on the rush, I couldn't let this slide. I had to defend my coworkers: "I think things went excellent up there. Considering that most of the people at that code never did that before, I thought things went awesome."

"Really, you thought that?"

"I have never left a code where I said to myself, 'Gee, Rick, I think everything went perfect.' I don't because there is always room for improvement. But considering the limited staff and the limited experience we have here, I think we did awesome."

Yet he continued to explain to me how there could be a lawsuit. I said, "Still, it's in your job description to help us. If there is a code blue you have to come, unless you're tied up with another more important situation. But I can't think of anything more pressing than a neonate that's not breathing. Can you?"

"Well, no," he said. Yet he spun off again on another rant about lawsuits. He's an awesome doctor, and I respect him deeply. I really do. And I understand where he's coming from. Yet sometimes it's best to do what's right now, do good charting, and worry about a lawsuit some other day.

Besides, all he did was put in the ETT and tried to save the baby's life. In fact, that's what we all did. Are we supposed to stand idly by and let a baby die because we might get sued. I don't think so.

In fact, I think we ought to make this RT Cave Rule #42:

RT Cave Rule #42: It's best to do what's right now, do good charting, and worry about a lawsuit some other day.

Dr's Creed: Bronchodilators now lowers Fever

The following might seem like nonsense to thinkers like you and me, but the Real Physician's Creed teaches doctors otherwise. Heed, what follows is surreptitious wisdom previously shared only with physicians.

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Section B7

A study performed by the Dr's Creed Association of America, and in association with the University of Michigan, provided a nearly conclusive conclusion that all post-operative patients that develop a fever should be provided with bronchodilator therapy.

The study included giving 2,000 post-operative patients at four key hospitals in the State of Michigan a bronchodilator if they developed a fever. Care providers for these patients eventually noted normal temps eventually, and the patients all eventually got better and were discharged.

Therefore, based on this study, we recommend all post-operative patients who develop a fever be given a bronchodilator.

Now, it has been noted that some respiratory therapists complain that a placebo of normal saline should have been given to 2,000 different post-operative patients who developed a fever to see if those patients would have eventually gone home too. Although we Docs know that would have been a wasted of time and money.

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Cord blood gases: Here's all you need to know

Every respiratory therapist dreads having to draw cord blood gases, and all OB nurses dread the circumstances that require them to be drawn. So, that said, what are the indications for drawing cord blood gases, what is the significance of drawing them, and why do we draw them in the first place?

Basically, the reason we draw cord blood gases is in case their is a lawsuit that might take place years down the road accusing the delivering doctor of causing an anoxic brain injury that resulted in diseases such as cerebral palsy.

The cord blood can prove that neurological deficits that develop in infants were caused by an anoxic brain injury that occurred after delivery or before delivery and was not the result of an anoxic episode at birth. The cord blood gas has been shown to be proof positive in about 80% of the cases (According to PubMed.com), and has in many cases cleared physicians from litigation.

A cord blood gas does not need to be drawn unless a baby is born has a low APGAR score within 5 minutes of delivery, such as a 3 or less. When the APGAR score is low a cord blood gas should automatically be drawn.

When we refer to cord blood we are referring to blood drawn from the placenta after delivery. If you look at a placental cord (see picture) you will see one large vein surrounded by two arteries that wrap around the vein.

According to PubMed.com, the Umbilical Vein delivers freshly oxygenated blood from the mom to the baby. Since an anoxic brain injury in baby in not likely to change the pH of the Umbilical Vein, this is not where you will want to draw a cord gas from.

The Umbilical Artery is where the baby's venous circulation dumps unoxygenated blood. This is blood that was on its way back to the mom's heart and lungs to pick up oxygen. Thus, when you draw a cord gas for litigation purposes you will want to draw from one of the two Umbilical Arteries.

Blood from the Umbilical Artery is called a Cord Arterial Blood Gas (CABG), and basically shows how the baby was doing prior to birth.

From this blood we want to watch for acidosis. Since anaerobic metabolism occurs during the absence of oxygen, the acid base balance (pH) of the baby's body increases due to increase in the amount of lactic acid produced. Therefore pH is the most important indicator in the CABG.

If the pH of the CABGis above 7.10, then we know that the baby was not hypoxic during the delivery, and if there was a hypoxic episode it occurred prior to the delivery process. It may have occurred weeks or months prior to birth, or it may have occured hours before birth. Either way, this proves the episode did not occur as a result of the delivery and should clear the physician of litigation.

If the pH is less than 7.10 the episode was more likely acute and the episode may have occurred during the delivery. If the pH is greater than 7.10, the episode typically occurred before the delivery.

According to obgyn.org, Some experts believe a pH of 7.0 with a significant metabolic component is a more significant sign of asphyxia at birth, and may lead to significant neurological dysfunction during life, or possibly even death.

Also according to obgy.org, "Even when this low pH threshold is used to define significant acidemia, most newborns in this category will be neurologically normal, with no apparent morbidity."

The baby's at greatest risk of anoxic brain injury are premature infants, according to obgyn.org. They are at higher risk of "intracranial hemorrhage and subsequent neurological dysfunction, such as cerebral palsy. Without umbilical cord blood gas analysis, these neurological complications could be incorrectly attributed to intrapartum or birth asphyxia, especially if the latter is solely based on APGAR scores. Normal umbilical cord blood values in the premature infant virtually eliminate the diagnosis of significant intrapartum hypoxia or birth asphyxia."

So, ideally, you will want the pH to be normal. If it is normal and there is an anoxic brain injury the doctor can prove by the CABG results that since the pH had time to return to normal the injury occurred prior to delivery and the injury did not occur as a result of delivery. If the pH less than 7.1 chances are the injury occurred during delivery.

Once a CABG has been drawn it can be set aside. Most studies now show that a CABG does not need to be placed on ice, and is good for up to an hour.

• pH: 7.28 (+/-.5)
• pCO2: 49 (+/-8)
• pO2: 18 (+/- 6.2)
• HCO3: 2.5-3.5
• BE: 10

Critical values that might show anoxic brain injury during birth (acidosis):

• pH less than 7.0
• CO2 greater than 50
• PO2 variable (remember this is the baby's venous blood, so the PO2 is relatively low)
• BE is normal or low (10 or less)

Critical values that might show injury due to metabolic cause:

• pH less low (less than 7.25, critical is 7.10 as mentioned above)
• PO2 less than 20
• CO2 is normal or high
• BE greater than 10 (Best indicator of metabolic cause

The following are conditions that would warrant a CABG:

• Any abnormality during delivery process
• Low 5 minutes APGAR score (less than 3)
• Any abnormality in patient condition that occurs within 1st 5 minutes after birth
• Premature birth
• Post term birth
• Meconium in amniotic fluid
• Intubation
• Positive pressure ventilation (Neo-puff or bag mask ventilation)
• Suctioning
• Cesarean-section
• Severe growth retardation
• abnormal fetal heart rate tracing
• maternal thyroid disease
• intrapartum fever
• multifetal gestation

The following are sources used for this post:

• OBGYN.org: Cord Blood Gases to Determine Umbilical Artery Acid Base Balance
• Umbilical Cord Blood Gas Analysis
• Cord blood analysis
• FamilyPracticeNotebook.com
• Tips for how to draw CABGs
• Umbilical cord blood gases: routine measurement may exonerate ob.gyns

What do parents need to know about asthma?

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

Question: We just found out that our 2 year old son has asthma.We do not know anything about this condition

My humble answer: You've come to the right place. There are lots of materials here that should help you in your quest to learn more about asthma. Plus you can read shareposts from asthma experts like myself (I grew up with asthma, in fact, I was diagnosed when I was 2). We write about what it's like to live with asthma, our advice to asthmatics and parents like you, and share the latest wisdom we learn.

Here is some basic information about asthma. Follow the links as there are several pages.

Here and here are posts I wrote a while back with you in mind. This post here is good too.

You should be able to recognize the asthma symptoms so you can act.

Which asthma meds work best. Here's a good post. While this is written for adults, the basic information is the same. You should discuss with your child's pediatrician which asthma meds work best for him or her though.

You should work with your child's doctor to create an asthma action plan to help you decide what to do when you observe the early signs of asthma.

You should know your child's asthma triggers so you can help him or her avoid them, or work with his or her pediatrician to treat them.

This should get you started.

The thing about childhood asthma to keep in mind is there is still a lot about this disease we don't know. Yet, with a good asthma doctor, asthma trigger avoidance, well educated and observant parents (like you), every child asthmatic should be able to live a normal life.

Good luck. And if more questions arise, please feel free to ask.