Capnography Cheat Sheet

Here is a capnography cheat sheet. It comes in handy from time to time For a printable version of this click on cheat sheets to your left, or click here.

Generic and brand names: why are there so many names for meds?

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: Is Ventolin in Canada the same as Albuteral? I get very confused with all these names of medications. The ones in Canada I think are called something else??

My humble answer: The medicine is exactly the same in both countries.

Merck.com explains all the names. I'll give a quick review here.

Every drug has more than one name. You have the chemical name that describes "the atomic or molecular structure of the drug." Usually this name is too complex for for the public to understand

Once the product is approved by the FDA it is given a generic name, which is basically an easy to pronounce version of the chemical name. Then the company comes up with a brand name that marks that particular product as made by that company.

Likewise, "When a drug is under patent protection, the company markets it under its brand name. When the drug is off-patent (no longer protected by patent which usually takes 25 years), the company may market its product under either the generic name or brand name. Other companies that file for approval to market the off-patent drug must use the same generic name but can create their own brand name. As a result, the same generic drug may be sold under either the generic name or one of many brand names."

Most doctors, nurses and RTs will refer to the drugs generic name, because it refers to the product itself not the company that makes it. Thus, a doctor will write an order for Albuterol. The pharmacy can choose whichever brand it wants. Usually it chooses the one with the lowest cost at that time.

For Albuterol it would look like this:

Generic name: Albuterol in the U.S. (Salbutamol in Europe and Canada)

Brand names: Ventolin, Proventil (AccuNeb, Vospire, ProAir in Europe and Canada)

Every one of the above refers to the exact same medicine, and they all have the same components, and thus all work exactly the same. So, yes, the Ventolin in Canada is the same as Albuterol.

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

Ancient asthma remedies

This post is the first in a series I plan on writing about the history of asthma. This was originally published at MyAsthmaCentral.com:

Check Out These 19th Century Asthma Remedies!
by Rick Frea Friday, December 18, 2009 @Myasthmacentral.com

Being a lifelong asthmatic, I've often wondered what life would be like for us asthmatics if we lived before rescue medicine like Albuterol was invented. I bet it would have resulted in some long, agonizing days and nights.

I was surprised to find there were many books written about asthma. The most popular was a 19th Century book called "On Asthma" by Dr. Henry Hyde Salter in 1882. His book provided remedies that gave hope to many child asthma sufferers, including Teddy Roosevelt. Although you might agree with Teddy that most of these weren't remedies at all, but torture.

1. Ipecac: It causes nausea and makes you vomit (sounds like fun). Salter observed that asthmatics with full stomachs had increased trouble breathing. He also believed irritants in food may cause asthma, so if you vomit and clear your stomach contents you will have an easier time breathing. (I'm not making this up).

Modern thought: A full stomach presses up on your diaphragm and thus squishes your lungs making it harder to breath. The irritants Salter is referring to in the food may now be known as food allergies. This medicine is thankfully no longer recommended for asthma.

2. Tobacco: Salter encouraged kids having trouble breathing to smoke cigarettes. But, instead of inhaling, hold the smoke in as long as you can -- literally "ad nauseum". For prophylactic therapy, smoke a daily cigar.

Modern thought: Smoke is an irritant. Not only that, smoking will increase your chances of developing COPD, and thus making your breathing worse in the long run.

3. Strong coffee: Salter observed sleepiness and drowsiness favored asthma. So, if you stay awake you won't have an attack. Strong tea, ammonia, and ether also work to produce this same effect. Go ahead and pick your poison.

Modern thought: The caffeine in coffee is a methylxanthine, which is a mild bronchodilator. Theophyllin is a methyxantine that became popular for asthma in the 1950s because it is a much stronger bronchodilator.

4. Indian Hemp: Otherwise known as marijuana. Like coffee, it increases your mental acuity. It makes you more vivid.

Modern thought: Marijuana is an asthma irritant. It too can cause more complicated lung problems down the road. It's an absolute no-no for asthmatics.

5.Alcohol: Recommended only in the face of "horrible suffering" because it is habit forming. Salter's theory was alcohol worked similar to coffee and hemp in that it stimulates and "gives a sort of shock.. to the nervous system..." and thus stops the asthma attack.

Modern thought: Alcohol has some molds and fungus in it that may trigger asthma. It also dries out your airway and may cause or make worse an asthma attack.

6. Chloriform: Again, I'm not making this up. Taken in small doses (and always in someone's company) it induces sleep, completely relaxes all your muscles (including your bronchiole muscles) and when you wake up your asthma attack will be gone.

Modern thought: It depresses the central nervous system and causes dizziness, fatigue, headache, nausea and even death. It may also damage the kidneys and liver. It is way too dangerous and risky to use for asthma.

7. Opium: It induces a relaxed state and thus cures bronchospasm. Salter didn't usually recommend it because he believed sleepiness induced asthma.

Modern thought: Morphine is a mild bronchodilator used in hospitals to cause a relaxed state that can reduce the feeling of dyspnea (air hunger) in end-stage lung disease like COPD, pulmonary fibrosis, cystic fibrosis and cancer.

8. Strammonium: Smoked in a pipe since ancient times for shortness of breath. Salter didn't recommend it for anything other than as a preventative medicine.

Modern thought: Atropine was purified from Belladona in the 1930s, and later was refined in the form of Atrovent and Spiriva. The Belladona plant is very similar to Strammonium. This line of medicine is no longer considered a top line asthma therapy, but is still used in some cases and in hospitals.

9. Lobelia: This is also referred to as Indian tobacco, as it was used by American Indians to induce vomiting and forcibly clear the airway of mucus. It was smoked in a pipe like Indian hemp, tobacco and strammonium. It is also referred to as "puke weed." This therapy was not recommended by Salter. But he said it works for some.

Modern thought: It was recently used as a nicotine substitute to help people quit smoking, but it was banned for use in cigarettes in 1993.

10. Ether: Salter wrote, "Ether is mentioned as a remedy... by almost all writers on the disease. I have never seen but one case in which it did any good."

Modern thought: It's only used as a anaesthetic in 3rd world countries.

Well, there you have it. Aren't you happy now you were born in the modern asthma era? So, if you were born in the 19th century, what poison would you prefer? If you're like me, you now appreciate your Ventolin all the more.

Competition should lower price of asthma meds

While Advair and Symbicort are have worked wonders for many asthmatics, these meds are not available to many due to their high cost. Yet soon, improved competition may drive down the price of both. I explain in this post from MyAsthmaCentral.com

Competition Heats Up for Advair's Share of the Market
by Rick Frea Monday, March 08, 2010 from MyAsthmaCentral.com

While the economy sputters, the long acting bronchodilator/ corticosteroid combination inhaler market is booming. While big pharmaceutical companies fight it out to maintain or gain a piece of this pie, we asthmatics should be the beneficiaries.

New drugs, and new marketing ploys, may soon be available in the U.S. market to compete with Advair and Symbicort, which will provide more options for asthmatics like you and me. Plus, as we all know, more competition means lower costs.

Advair and Symbicort are asthma combination inhalers that have both a long acting bronchodilator (LAB) to treat the airway narrowing (bronchospasm) component of asthma, but also a corticosteroid to treat the chronic inflammation side of asthma.

Advair (called Seritide in Europe), which is marketed by GlaxoSmithKline (GSK) out of London, became available in the U.S. in 2001, and presently has the lead in this booming market. Adviar consists of the LAB Salmeterol (Serevent) and steroid fluticasone propionate (Flovent).

Symbicort, marketed by AstraZeneca, became available in the U.S. market in 2007 to compete with Advair. Symbicort consists of the LAB Formoterol (Foradil) and steroid Budosenide (Pulmicort).

To improve it's share of the market, AstraZeneca is hoping the FDA will approve of Symbicort as a single-use inhaler, meaning asthmatics will be able to use it as both a preventative medicine and a rescue inhaler.

In May of 2010 the patent on Advair will expire (as you can read here), providing an opportunity for other companies to make and sell generic Advairs (like Seroflo) and gain a piece of this booming market.

Although, as you can read here, GSK sees little risk from generic Advairs any time soon. We can only hope, for our sake, GSK is wrong.

To try to maintain it's share of the market, GSK is hoping to soon release a new "Super Advair," which is also known as "Son of Advair." The inhaler will consist of a new LAB, currently called LABA 444, that only needs to be taken once a day, and a new corticosteroid, perhaps fluticasone furoate.

GSK notes early studies for "Son of Advair" show improved lung function and less risk for cardiac side effects, although other studies show the new corticosteroid is not much better than fluticasone propionate, the one in Advair.

Of course the company hopes to get all it's current Advair users to switch to this new drug before Advair generics are available. We'll have to wait and see how this turns out.

Other future entrances into this market (as you can read here) are Novartis/Schering-Plough's once-daily medicine which contains the LAB indacaterol and corticosteroid mometasone, SkyePharma's Flutiform (Formoterol and Mometasone), and Nycomed's Alvesco (Formoterol and ciclesonide).

All these attempts to maintian, or gain, market shares for these pharmaceutical companies means increased completion, and -- hopefully -- lower prices for you and me. Yet it also means more options for you and me and our doctors too, and -- ideally -- better asthma control with safer medicines.

Yes it's true, all this competition should benefit us asthmatics.

The impressive nurse

Erica was a relatively new nurse, and I had actually gotten annoyed with her before because she keeps calling me to give breathing treatments on patients where none are needed. Once she called me to give a treatment because, "the sat's only 89%."

However, oppinions are meant to be changed. A "Code Blue!" page rang out overhead, and I rushed to OB. As the code on the neonate progressed, I was getting tired of bagging and doing CPR. Then Erica showed up and joined in the rotation of bagging, cpr and rest.

She was so impressive, so calm, that I figured she had to be an old pro. Later, after the emergency was over, I approached Erica. She said, "That was the first code I had ever been to, and it just happened to be a baby."

I said, "That was your first code! Holy cow! You were so calm and cool and did such an awesome job I was sure you had done this many times before. I am very impressed!"

Nurses like this are definitely teachable, and fit onto our team well. I also think it's a good thing to compliment our fellow workers on a job well done, even if the outcome isn't what we expect.

Here's how to know if patient is a CO2 retainer

Question: How do you know how to tell someone is a PaCO2 retainer by looking at the blood gas?

My humble answer: It's easy. First, the CO2 will be chronically elevated. Usually, you'll find it in the 50s, but it can be as high as 80 on a good day. Second, look at the pH. If the pH is normal and the PaCO2 is elevated, you have a PaCO2 retainer.

Question: So, what if you have a patient who is laboring and has a pH of 7.20. Can you still tell if this patient is a retainer, when his PaCO2 is 80 or even 100?

My humble answer: Great question. Yes. What you do here is look at the BiCarb. If a patient is a CO2 retainer, his Bicarb will be chronically elevated. So, if you have a BiCarb greater than 30, chances are the patient is a retainer.

Question: Can you give a sample blood gas?

My humble answer: Sure. Consider ph 7.38, PaCO2 50, Po2 50, HCO3 35. That's a blood gas of a Co2 retainer on a good day. Note the CO2 is elevated and the HCO3 is elevated to compensate to keep the pH normal. This is a normal homeostatic procedure. So, if you had a patient in respiratory acidosis, his gases might look like this on room air: pH 7.20, PaCO2 80, Po2 36, HCO3 38.

Question: So what if the doctor sees that low Pao2 and high PaCO2 and thinks you got venous blood. How can you prove to him it was not venous?

My humble answer: Sometimes you can't. However, you know if you got the artery by how well it filled the syringe. Still, a doctor might not believe you. You can just tell him that the HCO3 is high, so chances are the PaCO2 is chronically elevated. If the patient is in acidosis, chances are the PaCO2 is elevated even more. It's worth trying anyway.  Another way to tell if this is arterial or venous is to place the patient on 100% non-rebreather. If the oxygen goes up, you know you had arterial. This is the best approach either way, considering a PaO2 that low is life threatening, and requires oxygen anyway.

Edited on July 5, 2016

MDIs: Priming the pump

Are you compliant with priming the pump before using a metered dose inhaler (MDI) like Albuterol? If you are, congratulations! I have to be honest: I'm not a pump primer.

So, what is MDI pump priming? It's when you waste 1-4 puffs of the medicine so that when you take it for real you are getting the maximum medicine available.

According to the American Associacion for Respiratory Care's "Guide to Aerosol Dellivery Devices," the following are the recommended Priming Requirements for Commercially Available MDIs:

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Medication Propellant Time to Prime # of Sprays Albuterols:

1. Albuterol* HFA Prior to first use 3 (With 3 days of nonuse 3)
2. Levalbuterol HFA Prior to first use 4 (With 3 days of nonuse 4)
3. Maxair Autohaler CFC Prior to first use 2 (With 2 days of nonuse 2)
4. Azmacort® CFC Prior to first use 2 (With 3 days of nonuse 2)
5. Flovent® HFA Prior to first use 4 (With 3 weeks of nonuse 4)
6. QVAR® HFA Prior to first use 2 (With 10 days of nonuse 2)
7. AeroSpan™ HFA Prior to first use 2 (With > 2 weeks of nonuse 2)
8. Atrovent® HFA Prior to first use 2 (With 3 days of nonuse 2)
9. Combivent® CFC Prior to first use 3 (With 1 day of nonuse 3)
10. Intal® CFC Prior to first use 1

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Despite the recommendation that all MDIs be primed before each use, I have never in my life ever done it -- not once.

I have good reason, though, for not doing it. First, when I learned how to use an MDI by my physician in 1980 the practice was never taught. Back then you were taught to place the inhaler two finger lengths from your mouth and squirt.

Second, when I was a kid I was a hardluck asthmatic and a bronchodilatoraholic. That meant that quite often my rescue inhaler (my Alupent back then) lasted me seven days or less, when it was supposed to last 4-6 weeks. So I had to do whatever I could to make the inhaler last longer, and that meant not wasting puffs.

Likewise, as a child asthmatic, I never wanted to bother my mom to run to the pharmacy, so that was another reason to make my inhaler last longer. Yet, even by not priming, my inhaler still only lasted about a week.

Third, I never heard of MDI priming until a few months ago. So after 30 years of not priming the pump, it's going to take me a while get into the habit. This is probably the stubborn me talking, but I really don't see a need to prime. Even if I'm only getting 2% of the medicine when I take my two puffs, that 2% seems to be sufficient. So I really don't see a need to prime the pump.

Yet theres an old saying this reminds me of: We do the best we can with the wisdom we have, and when we learn better we do better. So perhaps it's time to change my ways.As a respiratory therapist, I suppose I'm going to have to add pump-priming to my how-to-use-an-MDI regime.

So, what about you? Did you know about the need to prime the MDI pump? Are you an MDI pump primer? If you're an RT, do you teach this to your patients?

* Note that Proventil and Ventolin HFA have the same priming requirements.