Symbicort may be new asthma miracle drug

While the FDA is spending it's time recommending to doctors to get asthmatics off medicines like Advair and Symbicort once asthma is controlled, more common sense research seems to be looking in the opposite direction.

Read on, and decide for yourself if Symbicort might actually be the future asthma miracle asthma medicine

Symbicort May Offer New Option for Asthmatics
by Rick Frea Monday, February 22, 2010 @ MyAsthmaCentral.com

While it has not yet been approved in the United States, Symbicort may some day be available as a rescue inhaler as well as a preventative medicine. In this sense, it may be the dream inhaler we asthmatics have been yearning for.

In Europe, Australia, and recently Canada, Symbicort has been approved for this purpose. The program is called the SMART program, and you can read about it by clicking here.

According to asthmansw.org, SMART is an acronym for "Symbicort Maintenance And Reliever Therapy." The SMART program is explained here:

"It is a daily asthma management approach that allows you to use a single Symbicort inhaler as both a preventer and a reliever. Currently Symbicort is the only medication available for use as BOTH a maintenance preventer and reliever.

SMART works this way as it contains two different types of medicine in the same inhaler - a preventer (Pulmicort [Budesonide]) as the long-acting reliever which helps to control redness and swelling in the airways, and a reliever (Oxis [Eformoterol]) which can not only work quickly, but can also last a long time.

A person using the SMART approach to manage their asthma would take a maintenance dose of Symbicort, usually morning and night to maintain or establish asthma control AND they would also take additional inhalations of Symbicort as needed to relieve symptoms.

SMART is suitable for all people aged 12 years or older who are currently recommended to take combination medication for their asthma.

Symbicort has been available in Europe since since 2000, and was first made available in the U.S. in 2007 as a combination inhaler to compete with Advair (which presently is No. 1 in the U.S. market).

Symbicort works as a rescue inhaler because Formoterol starts to open the air passages in your lungs in two to three minutes as compared to 10 to 20 minutes for Serevent (the long acting bronchodilator in Advair).

Still, while it's approved as a rescue inhaler, the SMART programs limits the patient to eight puffs of Symbicort in any given day.

Likewise, it should always be used in concordance with an asthma doctor, and always as part of a physician directed asthma action plan like the ones linked to from this site.

By using Symbicort as a rescue inhaler, the asthmatic receives a boost of corticosteroid every time there is an asthma episode, instead of just using a rescue inhaler (like Albuterol). This basically allows the patient to increase his corticosteroid when he needs it, and decrease it when he's doing well. In this way the asthmatic has more control

Thus, "Studies have shown that people using Symbicort SMART - an additional way of taking the existing Symbicort inhaler - took no extra inhaled steroids and needed fewer oral steroids compared to traditional treatment methods. They also experienced fewer asthma attacks."

An Astra Zeneca sponsored study (the makers of Symbicort) noted the SMART program resulted in a 28 percent reduction in severe exacerbation compared to a regimine of using Symbicort twice a day while using something like Ventolin as a rescue inhaler in between.

According to this article at news-medical.net, researchers in the U.S. are reviewing data currently available and have "found no significant reduction in the number of asthma exacerbations that required hospitalization among the patients who used single inhaler therapy. However, the reviewers did find that fewer adults on single inhaler therapy had exacerbations needing a course of oral corticosteroids"

Researchers are also awaiting the results of five not yet to be released trials.

The pros of using Symbicort as a single inhaler are convenience, improved control, improved compliance, and that you will automatically be getting an additional boost of steroids right when you need it. This may especially benefit those who are compliant with their controller meds. (This asthma blogger does not like the SMART program).

A con of using Symbicort as a single inhaler is that for those who do not regularly use it, it usually takes two to three weeks for inhaled corticosteroids to start working, and therefore the added boost of corticosteroid may prove to be of no benefit.

So research is ongoing, and the debate, I am sure, will continue.

Whether the SMART program or something like it will ever be approved by the FDA is still open to debate. Yet if this is someday approved it will make available yet another alternative for physicians and asthmatics to try.

A great description of blunt doctors

I was called to do a STAT EKG (which didn't need to be stat, but that's beside the point). Even though it needed to be done so quickly, I was unable to get to the patient because the doctor was playing with the man's groin.

I watched as the urologist played with the man's catheter, while the nurse tried to assist him. The doctor was blunt and not particularly nice to the nurse. And I got the feeling the doctor also forgot he was working on a real live patient, and not motor in an engine.

The doctor said things like, "Well, why isn't this in your kit here?", "Where's the tape?", "Why is the tape on the floor? Come on!", " We need to be better at this!", "I need some gauze here!", "Come on! Come on!"

Anyway, I watched this procedure for quite some time. The nurse left the room once to get something while the doctor waited impatiently, and she smiled at me as she walked past me, and rolled her eyes too. She knew I knew the doctor was being ridiculous.

The patient was calm through this whole thing, and he said to the doc, "Normally I'd be embarrassed with my thing all exposed with all these people in the room. But for some reason I don't care."

"Well, we'll be done soon," The doctor said. "We just gotta get this done."

"No problem," the patient said.

Finally the nurse came back with another nurse. The rest of the procedure was finally finished, and I started my EKG.

As I did this, the patient said, "You know, I really like that doctor. I really trust him and I think he does a great job."

"Yep," I said, "He is a great doctor."

"The problem is, he has poor bedside manners."

"True, yet I think that comes with the territory."

"You know what it is," he said, "it's that he is brilliant. He's brilliant at what he does. What he doesn't realize," he paused a moment, perhaps drawing the best words from his brain, "is that we aren't brilliant at what he does. And he has trouble comprehending that. And, for that reason, he has poor bedside manners."

"Wow!" I said. "You hit the nail right on the head. I couldn't explain it better than that."

Even after dealing with doctors like that all the time, it's never easy keeping your mouth shut and not telling the doctor he's an ass. Yet, I have never heard anyone confront a blunt doctor in this way, and I hope I never do.

SVNs work no better than a simple MDI

One of the ongoing fallacies in the medical profession is that a small volume nebulizer (SVN) works better at delivering medicine than a metered dose inhaler (MDI). The truth is, with proper technique, they both were equally well.

Still, even thought the AARC's "A Guide to Aerosol Drug Delivery," notes that the dose of a medicine delivered with an SVN is two times greater than 2 puffs of an MDI, this doesn't matter: the end result is the same.

The guidelines note the following: "Clinically it is often thought that nebulizers may be more effective than MDIs, especially for short-acting bronchodilators in acute exacerbations of airflow obstruction. A number of studies have established that either device can be equally effective, if the lower nominal dose with an MDI is offset by increasing the number of actuations (“puffs”) to lung dose equivalence."

Thus, one test showed that 5 puffs of terbutaline had an effect on FEV1 (the best indicator on a bronchodilator's efficacy on obstructed lungs) as 2.5 mg of terbutaline given via SVN. So it's clear that an MDI is equally as effective as an SVN.

This is true "provided that the patient can use the device correctly."

Why are premature baby's at risk for complications

Why are premature baby's at risk for complications:

1. Large surface area, thin skin, less fat = easy to lose heat. When get hypothermic it stops breathing. So if you have a newborn it's important to make sure you have adequate warmth provided. This should be the #1 goal after you receive a sick baby.
2. Immature tissues sensitive to effects of oxygen
3. Weak muscles make it hard to breath
4. Immature nervous system makes it hard to breath
5. Surfactant deficiency (especially in premature infants)
6. Immature immune system = increased risk of infection
7. Fragile capillaries in brains may rupture
8. Small blood volume increases effects of hypovolemia
9. Oxygen can be toxic even to term babies. Do not overoxygenate.

The signs and symptoms of asthma

If you're an asthmatic, it's important you know your own signs and symptoms of asthma. If you're a doctor, nurse, respiratory therapist, mom, dad, aunt, uncle, teacher, friend, grandparent or guardian of an asthmatic, it's also important that you know the signs and symptoms of asthma.

That's right. Knowing your signs and symptoms and incorporating that into your personalized asthma action plan is essential. If you can notice a symptom early enough, you might be able to stave off an attack.

Likewise, if you have an asthmatic friend, coworker, relative or student, it's essential that you also know the signs and symptoms of asthma so you know what to do if the one you love, or the one you're taking care of, suddenly shows these signs.

That said, one of my recent posts at MyAsthmaCentral.com dealt with the signs and symptoms of asthma:

You Must Know the Signs and Symptoms of Asthma
by Rick Frea Tuesday, December 01, 2009 @ MyAsthmaCentral.com

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 specifically for the individual. A key part of this plan is understanding the signs and symptoms of asthma.

The signs and symptoms of asthma can be different for each asthmatic. Some signs and symptoms can be observed by others -- such as parents, grandparents, teachers, day care workers and friends -- while others can only be felt by the asthmatic.

Based on the signs and symptoms we experience -- or observe -- we can decide based on our asthma action plan what action to take next, such as what medicines to take, when to call the doctor and when to go directly to the emergency room.

According to NationalJewishHealth.org, your body gives you early warning signs of asthma, signs an attack is ongoing, and signs of severe asthma.

Early Warning Signs: These are signs that an asthma attack has not started yet, and actions you take can prevent an attack from coming (such as using your bronchodilator):

• Breathing changes
• Feeling tired
• Feel funny in chest
• Headache
• Easily upset
• Feel week
• Eyes look glassy
• Dark circles under eyes
• Feel sad
• Get excited
• Pale
• Stuffy nose
• Sweaty
• Feverish
• Grumpy
• Chin or throat itches
• Heart beats faster
• Coughing
• Sneezing
• Change in sputum
• Runny nose
• Dry mouth
• Trouble sleeping
• Poor tolerance for exercise
• Downward trend in peak flows

Signs of acute asthma attack: These are signs that an asthma attack is going on right now, and action must be taken to prevent them from getting worse (Like getting the asthmatic away from what triggered the attack and use of bronchodilator).

• Wheezing
• Coughing
• Shortness of breath
• Tightness in the chest
• Peak flow numbers in the caution or danger range (usually 50% to 80% of personal best)

Signs of severe asthma episode: According to NationalJewishHealth.org, "Severe asthma symptoms are a life-threatening emergency. If any of these severe asthma symptoms occur, seek emergency medical treatment right away, since these symptoms indicate respiratory distress."

• Severe coughing, wheezing, shortness of breath or tightness in the chest
• Difficulty talking or concentrating
• Walking causes shortness of breath
• Breathing may be shallow and fast or slower than usual
• Hunched shoulders (posturing)
• Nasal flaring (nostril size increases with breathing)
• Neck area and between or below the ribs moves inward with breathing (retractions)
• Gray or bluish tint to skin, beginning around the mouth (cyanosis)
• Peak flow numbers in the danger zone (usually below 50% of personal best)

When I learned about asthma signs and symptoms when I was a kid it greatly helped me control my asthma. Even today, while I don't let my asthma stop me from doing anything, when I observe my early warning signs I know it's time to stop and take action.

Therefore, you can see why I think it is of utmost importance for every asthmatic, and every person who knows an asthmatic or takes care of one, to know his or her own unique signs and symptoms of asthma, and to have an asthma action plan.

(For sample asthma action plans click here and here).

Note: The asthma guidelines recommend that you either monitor your symptoms or use a peak flow meter or both. The guidelines also note that both symptom monitoring or peak flow monitoring are equally effective.

How to deal with arrogant, all knowing physicians, and why progress is slow in respiratory departments

The following is a comment and my humble response regarding this post, where I wrote that breathing treatments do not work for CHF. I don't do this often, yet I felt this was worthy of its own post.

Your Comment: I look forward to your post about pneumonia and bronchodilators. I've had this discussion with several doctors and nurses. In fact, one nurse wrote me up when I told him that there was no indication to use Albuterol in pneumonia.

My humble response: I've had the same discussion with doctors and nurses. There's really nothing you can do when so many people choose to deny the facts.

Always know that the #1 sign of arrogance, elitism, ignorance and denial is to belittle the messengers of the truth. I can think of many examples, but you can find your own just by studying Hitler, Stalin and Castro. Anyone who disagrees with those folks was killed or imprisoned.

I agree with the Founding Fathers that it is only on the battlefield of ideas that the best ones can be recognized and ultimately prevail. Only those afraid of the truth seek to silence debate, and intimidate those with whom they disagree. This explains why RTs are criticized when they go verbal with the facts about breathing treatments.

On the contrary, Those who know they are right have no reason to stifle debate because they realize that all opposing arguments will ultimately be overcome by fact.

Yet those who champion breathing treatments for all that wheezes, for all that is short of breath, do not seem to understand that. If science is on their side, then why should they care who's against them? "The debate is over!" is a line that's used only by those who realize they would never win a debate.

In the end, it's not the debate itself, but those preventing it that are the truly ignorant. Honest listening and, more important, honest questioning is the foundation of the American experiment. We must listen to each other with renewed ears and speak out with passion, while also recognizing the difference between anger and truth.

That's why some doctors and nurses talk about RTs who state the facts as "lazy" and "trying to get out of work." Most doctors aren't this way, but the fact that some are scares us all into submission. It's kind of a do-you-want-to-take-the-chance kind of a situation.

I believe, however, that the fear of write-ups, of rocking the boat, and the desire to be politically correct and to "keep the peace" is exactly why we are in this mess in the first place. Too many times we RTs do the treatment not because it's needed, but because that's easier than confronting the ignorant. I know that sounds harsh, but it's the truth.

And I'm the same way. You'll rarely hear me saying to a doctor, "That's not a wheeze, it's stridor," or, "What good is a treatment going to do for inflammation of the alveoli, which is what pneumonia is." Because when I did use those words to question a doctor's order, the doctor and nurse got angry.

It's easier to just do the treatment and go back to the RT Cave. It's easier to just do the job they want you to do, go home and collect that pay check. It's easier to just go along. Your life will be so much easier if you just go along.

There's no controversy in agreeing with everyone, and not confronting ignorance and complacency. Because you're non-confrontational, You will have more friends as doctors and nurses will pretend to like you. It's easier, but is it really the right thing? Well, in a hire at will fire at will society, it is I guess.

This explains why RT bosses and admins tell us they understand during our monthly department meetings, and on occasion they accept one of our protocol ideas and vow to run it by the physicians, and when the pressure from "busy-don't-want-to be -bothered", "don't-want-to-give-up-autonomy", "don't-want-to-give-up-power" doctors rises, they back down and the protocol goes down with the rocked ship.

Yet, so long as you are polite and professional in your approach to educating doctors, you shouldn't need to worry about a write-up. Sometimes they can be good. Sometimes that's how the powers that be become aware of problems, and the seeds to solving the problem are planted.

Any RT who stands up and professionally approaches ignorance should be heralded. Many people resist change, even change that is based on facts and scientific data and common sense. They hate it. They would rather hold on to old fallacies. These people need to be confronted. They are resisting progress, and need to be held accountable.

So continue to be yourself, be careful as to know who you are confronting, and know when it's a good idea to back off and shut your mouth. It's also a good idea to know if you can trust your boss to back you up. That's the nice thing about my boss, so long as I'm not "complaining," he will always back me up, and my fellow RTs too.

However, unless you work for an elite teaching hospital where there are student physicians and Interns standing next to you while you're assessing a patient for an un-indicated breathing treatment, progress will be slow. So be patient, and keep up the good, peaceful fight.

How to deal with arrogant, all knowing doctors