Respiratory Therapy Cave

Weekly asthma FAQ

2009-11-10T03:32:00.000-05:00

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: I have been getting recurring pneumonia, could this be from advair?

My humble answer: You are not the lone person to come up with this idea as there has been much written on it, as is the case with this post here and this link here, and this one, and again here in this study. However, this study shows budosenide (an oral corticosteroid siilar to that of which is in Advair) does not cause pneumonia. So, I would imagine more research will be needed to come to a conclusion either way. The ideal thing for you to do is continue talking with your physician to make sure that the benefits to using this medicine outweigh the risks. In most studies, Advair (and Symbicort too) have been proven to be very effective for managing inflammation for asthma and COPD patients.

That aside, there are certain things you can do to try to prevent getting pneuonia that I describe in this post here: "Pneumonia: here's what you can do to prevent it."

Question: What in the body happens to cause asthma?

My humble answer: You've come to the right place to find everything you need to know about asthma. The best place to start is by clicking here or, better yet, here. By following these links you should get a good overall understanding of what asthma is and what "triggers" an asthma attack and what an asthma attack is.

No one really understands what causes a person to develop asthma in the first place, but there are theories, such as this one I wrote about.

The airways of most asthmatics are always inflamed (swollen) to some degree. Depending on the severity of this inflammation determines how bad one's asthma is and how sensitive the air passages are to asthma triggers.

When an asthmatic is exposed to his or her asthma triggers, this triggers the asthma response you can read about in the second link above. This ultimately leads to the air passages in your lungs (check out this link) to become increasingly inflamed (swollen) causing them to constrict (become narrow). When this happens air you breath can enter your lungs, but the narrowed airway traps the air in your lungs (this is called air trapping). Since an asthmatic during an asthma attack has this extra air in his lungs, it feels as though he can't get air in, but the truth is he can't get air out. He then feels like a fish out of water.

Fortunately there are medicines to treat an acute (ongoing) asthma attack like this and even more medicine to prevent an asthma attack. You can read about asthma medicines here.

If you want to read a very thorough writing about what asthma is, you should check out the asthma guidelines I will link to here. Actually, the answer to your question should be in this section.

Good luck.

Question: I have asthma and taking 4 life transfer factor as remedy. i was told by a friend that he has taken 4life transfer factor pills for his immune system and that his asthma has gone away . is this 4 life product as good as they say it is ?

My humble answer: I can neither deny nor confirm this claim. However, I'm sure if this worked to "cure" asthma it would be all over the news and on the front pages of this site. You have to realize that asthma has a tendency to appear to "hibernate" for weeks, months, and sometimes even years. It may be a coincidence that your friend started taking this 4 life transfer factor at the same time his asthma went into hiding. However we want to remain open minded, so the best thing for you to do if considering this is to discuss it with your asthma doctor and continue to keep up on your asthma research for the latest asthma wisdom.

Question: Coughing lots especially at night. Sometimes it leads to vomiting. My doctor says I just have a cold. Is he right?

My humble answer: We really cannot diagnose over the Internet. It is not completely abnormal for a coughing spasm to lead to vomiting and a headache. A common cold can cause nasal drainage which would induce a cough. Bronchitis, asthma, and a lung infection may also cause increased sputum production and induce a cough. Which one of the above is causing your symptoms is something only your doctor can determine.

Question: I am 25 yrs old girl I always get breathing problem whenever i cry a lot or get tired. Is this a symptom of Asthma?

My humble answer: Actually, what you are describing is not a symptom of asthma. To see what the symptoms of asthma are click here. That said, emotions can be an asthma trigger. Asthma triggers are things that can "trigger" an asthma attack. To learn more about asthma triggers click here.

There are some things you can do to help prevent emotions from effecting your asthma. First, you should discuss this with your asthma doctor. Second, you might want to learn and work on some relaxation exercises. When you get emotional you can work on "relaxing" and this can help prevent this from causing asthma.

Better yet, setting aside 5-15 minutes each day to concentrate just on relaxing your body might prevent emotional asthma altogether. Trust me, I've tried this and it works great.

When I was a teenager I had asthma that was triggered similar to what you describe here. Whenever I was tired, stress or anxious I'd have trouble breathing. Fortunately I knew a great asthma nurse who taught me some great relaxation techniques. One I mention in this post, although this post describes relaxation techniques better.

You should also mention this to your doctor, because he or she might have some more ideas that might help.

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

The link between asthma and COPD

2009-11-09T14:29:00.002-05:00

A doctor told me once that if you have childhood asthma that doesn't go away when you grow up you are said to have COPD. As a former child asthmatic. He also said once, "If you ever smoke I might as well just kill you."

I think about what he said often. Recently I decided to do some research.

I've learned that most of the time when we refer to COPD (Chronic Obstructive Pulmonary Disease) (COPD) we are referring to people who smoke. This is rightly so because, according to nationaljewishhealth.org, 94% of those with COPD are people who smoked cigarettes.

That said, there are still 5% of COPD patients that often go unaccounted for. Almost 1% of these get COPD "by genetic-based deficiencies in an enzyme called alpha-1 antitrypsin," according to National Jewish.

The other 5% get COPD either get the disease from "exposure to various types of dust such as coal, grain, or wood or by recurrent or significant lung infections in infancy and early childhood."

People with asthma are among those most likely to be hospitalized with lung infections, and therefore asthmatics fall into this 5% too.

So now we see where the slight overlap of Asthma and COPD comes into play (see picture). A small percent of asthmatics, if their asthma is not controlled appropriately, can develop lung scarring over time that results in permanent lung damage that can cause them to have chronic persistent asthma/ COPD.

It is these asthmatics who are your hardluck asthmatics (I think). It is these asthmatics who are staged to become your bronchodilatoraholics, and who require the use of rescue medicine on a daily basis.

I have written here before how I have a need for my rescue medicine on a daily basis for relatively mild symptoms, and have to constantly be vigilant for my asthma triggers because my lungs are "more sensitive" than the lungs of most asthmatics.

I also learned that asthma is often misdiagnosed as bronchitis. From my medical records I've learned I had frequent bouts of "bronchitis" before I was 2. Chances are I was misdiagnosed, because I was diagnosed with asthma when I was 2-years old. Plus there were lots of asthma attacks. All of this, I bet, caused my asthma to get as bad as it did.

Keep in mind here I'm just speculating, but it makes sense to me. To be honest, I don't think even the worlds formost asthma experts would know exactly why asthma sometimes gets so bad. Although there are many theories.

There is a small area where the circles of asthma and COPD overlap (again, see picture). I would guess that less than 10% of asthmatics fall into the COPD category. Yet I've read in "Egans Fundamentals of Respiratory Care," that anywhere from 15-70% of those with COPD have the asthma gene.

From my own asthma history and from my recent research I've learned two things I would like to share with my asthmatic readers.

1. Childhood asthma is better diagnosed and better treated today as compared to when we were kids. So chances are our asthmatic kids won't get as bad as we are, and won't push their asthma into the COPD category.

2. If you had asthma as a kid you better never touch a cigarette. If you do you're playing with fire (literally), as you are risking pushing your asthma into the COPD category, as I would imagine the Recovered Asthmatic is doing.

Swimming and asthma

2009-11-08T02:58:00.001-05:00

I've found something that bothers my asthma every time -- swimming. I can still do it, but I most certainly need to pace myself.

It has been written by many asthma experts that swimming is among the best exercises for asthmatics. When I was a kid I used to go swimming all the time. We had a neighborhood pool and a beach a mile from where we lived. Yes I had trouble breathing when I exerted myself under water sometimes, but for the most part I handled it pretty well

When I was at the asthma hospital in 1985 the asthma experts there had us asthmatics swimming at least three times a week. So even way back then (I make myself sound old here) the experts were recommending swimming for asthmatics.

I don't swim nearly as much as I used to, although I do take my kids for a swim in Lake Michigan from time to time since I live so close to it. And when we go on vacation I take my kids for a dip in the pool. Yet one thing that remains consistent: swimming makes me short of breath.

I stay physically active and I even run without having trouble with my breathing. I wasn't always able to run as I also have exercise induced asthma, although my asthma has not bothered me when I exercise lately. So this makes me wonder why it would be EIA causing my shortness of breath while swimming. Although this is a good possibility.

As my regular readers know by now I had hardluck asthma until a few years ago. I don't have trouble breathing throughout most of the day anymore. When I do it's usually mild and is resolved with a puff or two of that blue inhaler we call Albuterol.

Yet, despite what I write here, every time I get in the water my chest gets tight.

I guess I noticed it more on this vacation because I was in the water every day. And since my kids are older and now know how to swim I was actually able to do a little swimming on my own. And after that first time racing my son to the other end, I noticed my chest was heavy. I had to get out and rest. I didn't get all the way out, just sat on the top step with my chest out of the water. I doubt anyone watching had a clue why I was sitting there. I don't think I was obviously short of breath. I tried not to be obvious anyway.

While I usually can make it from one side of the pool to the other without coming up for air, I was only able to do this once and I was done. I had to sit and rest. I had to literally get my chest out of the water to get relief. And that's what made me wonder: was it the exertion under water that hit me (EIA), or was it the pressure of the water against my asthmatic lungs. Or was it the chlorine. However, if it was the chlorine then I wouldn't get short of breath while swimming in the Lake, and I do.

The next day I went under water and was fine until I challenged my son to another race. I was able to beat him a second time, but that was while dealing with a tight chest and taking in only what felt like 3/4 of a breath each inhalation. I wasn't completely miserable by no means, but there was definitely some discomfort.

The next day I decided I was just going to put my chest under water and not exert myself. I wanted to see if just the water pressure alone would make me short of breath. Well, I'm not the kind of person to just sit still, and after a few minutes I was tossing my 11-year-old into the deep end so he could have his fun. Then my 6-year-old wanted to get into the action. Before long my chest was tight. Yet I continued to toss my kids for some time. Eventually, though, I knew it was time to quit.

Now I have to add that the shortness of breath I got by being in the water was not relieved by my bronchodilator. In fact, after the first few times I decided not even to bother using it. It was the kind of shortness of breath that you had to wait out. If you have asthma maybe you know what I mean. I wasn't sick enough to panic because I had been here before. I JUST KNEW I would be fine if I just waited it out.

But I didn't want to wait it out. I wanted to swim some more with my kids. So I did. My son mentioned something about this to me about the fifth or sixth time we went into a pool. He said, "Dad, why is it that every time we get into the water you race me less and less?"

Well, I didn't want to bother him with my problems. I wanted him to be having fun. And I had a great time too. I knew that once I got out of the water with the kids and rested a while I would be fine. I knew my asthma was controlled enough (I'm a gallant asthmatic) that I'd be perfectly fine within 10-15 minutes post water.

This turned out to be true every time. I'm telling you, it's an awesome feeling and a comforting feeling when you know your asthma so well you know exactly what you can and cannot do based on the type of shortness of breath you experience.

(Believe it or not there are different types of shortness of breath; different feelings you get in the chest. This is a topic I think I will take up in another post).

And the type of shortness of breath I was feeling was one I knew I would be fine once I rested. It's power I suppose. It's power over myself. It's vigilance. If you have asthma as long as I have you know what I mean. After a while you just know yourself; you know your asthma; you know exactly what works and what doesn't; you know exactly what to do and when to do it.

It's also an awesome feeling as you slowly but surely notice the pressure in your chest giving way, and the air getting deeper and deeper into your lungs with each breath. And all of this without taking one puff of your rescue inhaler. In a way, it creates (I wrote about this before) a feeling of euphoria. Likewise, it creates an appreciation for breathing. You experience this once and you'll never take breathing for granted again.

Swimming is fun and I'm going to do it again next chance I get. And you can bet I'll be holding my breath the length of the pool, or doing laps. You an bet that some day soon I'll be wrestling with my son under water, or tossing my kids into the air and watching them giggle while they splash in the water. It's fun. And no asthma beast is going to take away this fun from me.
Another thing I wonder is if I swam every day if my lungs would get even stronger and these episodes of shortness of breath due to water immersion would cease.

See I'm curious this way.

Here's why we don't have protocols

2009-11-07T03:33:00.001-05:00

Ideally, according to Egan, a protocol would work like this:

Therapy can be adjusted more frequently in response to changes in patient status.

Physicians can still be contacted for major changes, but not minor adjustments, thus reducing nuisance calls.

Consistency of therapy can be maintained and nonpulmonary physicians can use appropriate up-to-date methods by simply requesting that protocol therapy be used.

RCPs become actively involved in achieving good patient outcomes instead of performing rigid tasks. This enhanced responsibility attracts and retains better educated qualified practitioners.

Doctors here at Shoreline don't want any of these, and therefore have elected to ignore pleas of lowly RTs.

They don't want frequency to be adjusted. Thus Q4ever for everyone.
They aren't worried about nuisance calls because when they get them they double the frequency and add IPPB that RTs hate.
Nonpulmonary physicians don't have to worry because Q4ever works for everyone regardless of diagnosis.
Physicians don't believe RTs have are smart enough to know who needs therapy. Likewise, RT Bosses don't have to worry about attracting and retaining qualified RTs because there are no other RT departments in this area for us RTs to go.

No consistency

2009-11-06T21:00:00.001-05:00

Do you ever wonder about consistency at your hospital when it comes to physicians? Sometimes the "inconsistency" can give us RTs a headache.

Consider the following:

Dr. C lectured me that it's not the role of RTs interpret EKGs

Dr. X lectured me that it is the role of RTs to interpret EKGs, and lectured me when I didn't call him with the interpretation (we don't have an in house doctor at night here)

Consider the following:

Dr. A orders Xopenex on all his patients (He said, "Xopenex is the almighty med")

Dr. B orders Albuterol on all his patients (she agrees Xopenex should be called Hoaxenex)

Dr. C. orders Duoneb on all his patients

Dr. D. orders Xopenex with Atrovent on all his patients

Dr. E orders any combo of the above, and sometimes just Atrovent alone

Dr. F lets me order what I want and at any frequency, "Just let me know what you do."

Dr. G lets me order what I want and at any frequency, "Just let me know what you do."

Consider the following:

Dr. A is an ER doctor who wants me to hunt him down and show him all EKGs

Dr. C is an ER doctor who wants me to hunt her down and show her all EKGs, and lectures me when I don't.

Dr. B is an ER doctor who does not want me to hunt her down with every EKG, that I'm fully qualified to know what one's to take to her right away

Dr. F and Dr. G are both ER doctors and they trust me to use my common sense

I can tell you when Dr. F and G are working my morale is highest, and when I have an opinion I am quick share it with them. If I think someone needs a treatment I will give it, and when I give an assessment with share the results.

The other ER doctors act as though my opinion, my expertise, and my education are no different than that of a hospital volunteer, and treat me as such. When these doctors are working my morale is lowest.

It would seem to me a protocol would not only benefit these doctors but the morale of us RTs too. However, both doctor F and G have made it quite clear they would overrule a protocol even if there was one. But that's fine by me as they have that right.

Still, is my hospital the only one with this much inconsistency?

The COPD Action Plan

2009-11-05T09:37:00.002-05:00

Other than quitting smoking, one of the most important steps for any patient with Chronic Obstructive Pulmonary Disease (COPD) is to work with his doctor on a COPD Action Plan. This plan will help him decide exactly what to do when he observes his early warning signs of an impending COPD exacerbation.

Way too often I have a COPD patient come into the emergency room who waited way too long to seek help. This is usually the case with that first exacerbation. The patient may be scared and doesn't really understand what's going on. Or, he is modest and thinks by taking extra breathing treatments and over medicating can solve his problem on his own.

Usually, however, waiting too long to seek help when you have COPD only makes the exacerbation worse. So, to help COPD patients decide what to do next time this happens, we educate on what a COPD Action Plan is.

First they must be vigilant and pick up on their own early warning signs of COPD. The next time they see any of these signs they need to put this plan into action. What follows is a sample plan from NationalJewishHealth.org that I think should work pretty well for most COPD patients. However, every COPD patient should work with his own doctor to build a plan tailored just for him.

Here is a sample COPD Action Plan from NationalJewishHealth.org:

Call immediately: If forgetfulness, confusion, slurring of speech or sleepiness occurs during an acute respiratory infection.

Call within 6-8 hours: If shortness of breath or wheezing does not stop or decrease with inhaled bronchodilator treatments one hour apart.

Call within 24 hours: If you notice one or more of the following severe respiratory symptoms:

Change in color, thickness, odor or amount of sputum persists

Ankle swelling lasts even after a night of sleeping with your feet up

You awaken short of breath more than once a night

Fatigue lasts more than one day.

It's that simple. Teach your COPD patients how to stay out of the hospital by providing them with this COPD Action Plan, or by encouraging them to create one of their own with their doctor.

If you have COPD, well here you go.

Sure the COPDer might require an occasional recharge at a nearby hospital. But by following a good COPD Action Plan most exacerbations should easily be treated by a simple call to your doctor and a quick visit to his office.

How to hear bronchospasm

2009-11-04T09:19:00.002-05:00

It has been said that it takes a trained ear to hear bronchospasm. There is much truth to this statement. So, that in mind, I have decided to create a lesson here on how to hear bronchospasm. This might be good for all nurses, respiratory therapists, students and even doctors to review.

First of all, the patient has to be breathing. If you are hearing no lung sounds then you know you are not hearing bronchospasm. Likewise, if a patient is breathing normal, is not short of breath, and has good air movement with clear lungsounds, you are also not dealing with bronchospasm.

Many people believe if you hear a wheeze it's automatically bronchospasm and a bronchodilator breathing treatment is indicated. They jump the gun and scream, "Hey Respiratory! Give this guy a treatment!"

The truth is, not all that wheezes is bronchospasm. Heart failure and pneumonia cause more wheezes than bronchospasm. The fluid from heart failure or pneumoonia causes increased pressure in the lungs and squeezes the air passages from the outside causing a wheeze that is quite often heard in the throat. This, my friends, is called a Cardiac Wheeze and must not be confused with a bronchospasm wheeze.

Here are some tips to help you learn to hear bronchospasm:

Shortness of breath alone does not indicate bronchospasm. Or, stated another way: All that wheezes is not bronchospasm. Before you rush to call an RT for a bronchodilator you should assess the patient further to determine WHY the patient is short of breath.
If patient is not short of breath there is no bronchospasm, and no bronchodilator is indicated. Nuff said.
If it's an audible wheeze it's not bronchospasm. Usually if it's audible what you are hearing is fluid sitting on the vocal cords. Many experts consider an audible wheeze stridor, and stridor is not a wheeze at all. If you hear an audible wheeze consider pneumonia or heart failure and check or watch the patients fuid intakes and outtakes.
A bronchospasm wheeze is NEVER audible. True bronchospasm wheezes are within the air passages of the lungs and can only be heard by auscultation. They will also NOT be heard in the throat. (Yes, I know I repeated myself. This is an important point.)
Listen to the throat. If you hear the wheeze by auscultating the neck area it's an upper airway wheeze, and is usually associated with excessive secretions or pulmonary edema (again think heart failure or pneunomia). If you hear this watch this patient for signs of fluid overload. Sometimes you will hear a "throat wheeze" radiating throughout the lungfields.
Have patient breath normal. When a patient is taking a deep breath you are more likely to hear upper airway noises that overshadow underlying bronchospasm. A true bronchospasm wheeze is best heard with normal, slow, laminar inspiration and expiration.
Have patient relax. This sort of goes along with #3 above, but it had to be said. Many times a patient is anxious and breathing fast and this moves secretions around causing dyspnea and wheeze. Usually the cause of dyspnea with exertion is cardiac related and what a patient needs is an oxygen boost and/or rest -- not Albuterol.
Have patient breath through pursed lips. If you really want to tell if a patient actually has bronchospasm, have them breathe through pursed lips. This forces them to breathe normal and you will not hear the upper airway component, and are more likely to hear the bronchospasm wheeze if it exists. You may need to listen closely, because a bronchospasm wheeze can sound very distant. This is a great trick.
Listen for diminished lungsounds. Bronchospasm usually results in diminished or decreased air movement in the lungfields. If a patient has good air movement even with other adventitious lungsounds, the odds are that the noises are not caused by bronchospasm. (Click here to learn why I think diminished lungsounds is better indicator of bronchospasm than wheezes.)
As a rule of thumb, bronchospasm wheezes are usually expiratory. If you hear an expiratory wheeze you can consider bronchospasm. If you hear an inspiratory wheeze chances are you're hearing bronchitis.
Exceptions to the rule. Sometimes the patient can have an upper airway wheeze or cardiac wheeze and also have an underlying bronchospasm component. In this case you may want to try one bronchodilator treatment and see if the patient gets better. If it doesn't work don't be the fool who orders continuous breathing treatments for no reason and overlooks what the patient really needs (perhaps some Lasix?).
If you hear increased lungsounds after the treatment you had bronchospasm to begin with. However, if the patient had good aeration before and after therapy, consider no bronchospasm existed and tell the nurse and doctor to try something else (if they'll listen to you).
Quite often, the best inidcator of bronchospasm is no wheeze at all. This is especially true with adults. So don't assume just because a patient isn't wheezing that he's not having bronchospasm.

For more information check out the following posts:

Indications for breathing treatments.
SOB not always caused by bronchospasm

Asthma Q&A: Is asthma considered a disability?

2009-11-03T05:33:00.001-05:00

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: what can help the coughing go away?

My humble answer:
You should know first off that a cough is a good thing, as it is one of your bodies self defense mechanisms to keep your lungs free from foreign particulates like bacterias and viruses. So, while it can be uncomfortable and annoying, it is actually something that's good.

That said, why are you coughing? Are you having an asthma exacerbation resulting in excessive sputum your body is trying to expectorate (spit up)? If this is the cause, it can be treated with various asthma medications.

Do you have a lung infection (like pneumonia)? If this is the cause perhaps your doctor might want to treat the infection too.

Cough medicine may treat the cough, but it may not treat the underlying cause of the cough. To find out the cause, and to treat it, you will need to contact your doctor.

Question: Are my asthma inhaler (Symbicort) supposed to stop me from coughing completely? I've had a chronic cough for two years now and a chest x-ray and PFT confirm I had asthma.

My humble answer: I like to think of asthma as more of a conundrum (a riddle) than a disease. It can come on suddenly, and it can disappear for days, weeks and even years. In some cases it may be easy to prevent, and in some cases this may be difficult. Likewise, what works for one asthmatic may not work for another.

You say that you have had a cough for a long time. This is one of the signs of asthma as you can see by this link. And one of the best ways to diagnose asthma is by looking at PFT results, as your doctor has done.

I can tell you from my own first hand experience with asthma that it can be a tricky disease, and it may take some time to get it under control. It may also take time, and some trial and error, to find the best asthma medication that works best to control your asthma. You can read about all the asthma meds in this excellent post.

Ideally you'll want to find an asthma plan that stops all asthma symptoms, including the cough. Depending on the severity of your disease, some symptoms may not completely go away.

Another thing you may want to consider, aside from asthma medicines, is the way you live your life. Are you avoiding your asthma triggers?

Question: Is taking foracort 100 without prescription harmful as it is a steroid?? is playing cricket harmful?? I'm 16 and I love Cricket and I live in Bangalore. But the thing causing me to have trouble playing cricket is my asthma. Can I please get a remedy which can help me cure asthma once for all n relieve me from it?? Also , I take foracort 100 mg quite regularly whenever i feel hard to breathe , that to without any prescription!! is that very harmful for me??

My humble answer: Foracort is a medicine meant to prevent you from having an asthma attack. It should never be taken more than twice a day, and there can be serious consequences of using it more often then twice a day.

That said, I think Foracort is a great medicine, but it seems that this med alone is not going to control your asthma. Perhaps there are certain asthma triggers you are exposed to and can work harder to avoid. Perhaps you need a higher dose of Foracort. Perhaps there are other meds that may work best for you. The best way to find out how better to control your asthma is to educate yourself about this disease right here on this site, and by finding a good doctor who will work with you to manage your asthma.

There really is no reason you should have to quit cricket because of your asthma. While there is no cure for this disease, it can definitely be controlled.

Question: can you get asthma for dogs?

My humble answer: Asthma is not a disease you can get from dogs. Asthma is an autoimmune disease and no one knows for sure exactly what causes it, however there are theories. What we do know is that asthma is a disease where your immune system recognizes things that are harmless (such as dog dander) to most people as dangers, and develops a response to those things. That response thus results in an allergic reaction and an asthma attack. So, in that sense, a dog can be an asthma trigger, but it does not cause one to develop asthma.

Question: Need to use expired Advair HFA... I stocked up on inhalers when I was insured, and now I need to use my Advair HFA again, but it's expired. I have no way of replacing it... Please, what do I do??

My humble answer: Research I've done about expired asthma meds show that while they may lose potency over time, they are not unsafe to use. I personally have never used an expired Advair inhaler, but I have used an expired Albuterol inhaler with good results (although the med starts to taste funny after a while). I'm not encouraging you to use expired meds, just throwing that bit of information out there.

There may be some options available for you. I will provide you some links that might help:

I don't have health insurance and I can't afford advair, What can I do?
affordable medications

You might also want to discuss this with your physician, as perhaps he might be able to prescribe an alternate medicine to control your asthma that is less expensive than Advair.

Question: Is having asthma consider an disability? have asthma and been in the ER since July thru mid Sept about 5 times. Is having asthma an disability.

My humble answer:
Generally speaking asthma is not considered a disabling disease, mainly because asthma is a disease that can be controlled in most cases. Sure you might have to make some changes in the way you live, but it shouldn't be disabling. You might have to get a new job where your coworkers don't smoke and you aren't exposed to asthma triggers. You may have to pace yourself when exercising. But, with good asthma control, you should be able to live a relatively normal life.

On the other hand, there are some cases where severe persistent asthma gets so bad that asthma can become a disability, although I'm sure this is pretty rare.

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

The swine flu vaccine: get it, or not!

2009-11-02T03:12:00.003-05:00

There are laws that say you have to wear a helmet if you ride a motorcycle. There are seat belt laws that say you have to wear a seat belt. But there are no pig flu vaccine laws that say you HAVE to get the pig flu vaccine.

(You can learn more about the swine flu by clicking here and here. To learn the difference between influenza and the stomach flu click here)

I'm not saying you shouldn't get it. I'm not saying you should. I'm not saying you need to panic because there is an impending pandemic. I am not saying there will not be. I'm not a pig flu expert, yet I am educated as you are.

I'm not saying the swine flu vaccine is completely safe and I would definitely let my kids get it. I'm not saying it is unsafe and I wouldn't let my kids get within a 10-foot pole's length from the pig flu vaccine.

However, there are those who would argue both sides. You have government officials for the CDC and in the Whitehouse saying the pig flu vaccines that didn't exist a few months ago are completely safe.

Then there doctors like Doctor Ken Hartoff (an infectious disease expert) who said the following on Fox News (see video here):

"I have more concern about the vaccine than I do about the swine flu. It's been rushed to market. There are high levels of adjuncts, which make it more potent. It's kind of an unrefined method that they used."

Likewise, he added that it has antiseptic preservatives in it that has "been shown to cause autism in children with mitochondrial dysfunction... and the problem is you don't know if your child has mitochondrial dysfunction. I also worry about children, pregnant women, chronic neurological illnesses, and chronic fatigue syndrome and fibromyalgia. I've seen people (who have been) devastated by these vaccines."

On the other hand, the NYDailynews.com notes Health and Human Services Secretary Katherine Sebelius said, "I think that the flu is serious, that we have a very targeted vaccine and we'd like people to take advantage of it - it's the best way to protect themselves."

Dr. Thomas Frieden, director of the U.S. Centers for Disease Control and Prevention, notes:

"This is the same vaccine factories, the same companies, the same process that's used every year for seasonal flu. We know that it has an excellent safety record, and we are confident it will be safe."

So should we be scared about the pig flu vaccine or should we be scared about a pandemic. The truth is, you have to make a common sense decision based on the facts, and weigh the posible risks against the potential benefits.

Of course, we also have a history of the government being wrong. We had the government telling us in 1976 there was going to be a pig flu pandemic (I wrote about that here), yet more people died from the vaccine than the flu that year.

So now we have people scared of the vaccine, and for good reason. And we have people scared there might be a pandemic. However, while the flu may have caused a pandemic in 1909, medicine has come a long way since then. And while the vaccine may have been bad in 1976, the way they are made today are said to be much safer.

Now, I certainly don't want to get the flu, and I dont' want any one else out there to either. But is this really something we need to worry about, or something "they" just want us to worry about.

My place of emplyment is worried about the pig flu and the bird flu too for that matter, and has a plan of action in place just in case. They expect 40% of the workforce to be sick, and expect one nurse to take care of 10 patients. That's the plan.

They expect that to be a worse case scenerio. One good thing about this "scare" is we now have suction and oxygen regulators in every room, something the admins here at shoreline were reluctant to order due to cost prior to the scare.

And we got a new Vision and 2 new transport ventilators all free from the homeland security department. Although they weren't really free, as we all paid for them.

I had the flu wipe me out once. That was back in 1998 and I ended in the hospital with a bad asthma attack for 10 days. So getting the flu is nothing to take for granted.

The regular flu shot I think is proven safe for most people. I'm not letting my kids get it because I don't think they need some of the ingredients that are in it, but I get it. I get it because I can't afford to get sick, and I owe it to my patients not to give them the flu.

The pig flu vaccine, however, I'm not getting unless someone tells me I have to get it or I'll lose my job. Call me naive, but I dont' want to be a guenne pig, and I definitely don't want my kids to be guenne pigs. It stuns me when I see hundreds of people waiting in lines to get the vaccine, all of them obviously trust the government more than I do.

I'm not alone in not wanting my kids to get it, as according to Yahoo Health 40% of parents will not let their kids get it. But the reasons stated in the article are not the same reasons I have. The article notes the 1976 scare as the main reason people are "leary" of the swine flu vaccine. I'm leary of it because of long term unknown side effects as those mentioned by Dr. Frieden.
And my place of employment can legally tell me to get it or they'll fire me, because they don't need a reason to fire me. Your hospital and mine can fire either of us on the spot for any reason it chooses.

So, to fear the pig flu or not to fear the pig flu. So, to get the pig flu vaccine or not to get the pig flu vaccine. Those are your decisions to make. You have the freedom to choose You have the right. You have the right to be smart. You also have the right to be stupid.

My point here is the RT Cave is niether endorsing the pandemic scare nor telling you it's a hoax to sell vaccines so the company that makes it can make money (of course only one U.S. company has the guts to make such a vaccine due to the 1976 scare, so it won't benefit our economy much).

My point here is neither to tell you to get yourself vaccinated with the pig flu vaccine nor to tell you you must get it. It's your choice. Do your research. Be responsible.

I mean be responsible. If your boss says you have to get it you will have no choice but to get it, unless you prefer to find another job. And even if you get a new job your new place of employment may also make you get it.
----------------------
Ah, one more thing. If the U.S. government mandated that everyone in the U.S. get the vaccine like it did in 1976 (it stopped the mandate after it realized the vaccine was killing more people than the flu), lawyers have confirmed you will have to get it or face the punishment whatever it be.

And yes the fed does have the power to put you in a confinement camp if it chooses (although when the fed has done this in the past it has not gone over well with the people).

If the government does decide to mandate this pig flu vaccine, there is only one legal grounds you have to not get it, and that is for religious or health reasons. So, if you wish to be adamant about not getting the vaccine, you had better start looking for a religion that is opposed to it.

One of my coworkers said she's going to make up her own religion and call it the vaccine religion.
-----------------
Update: After I wrote this I ended up getting both flu vaccines. I have a band aide on each arm to prove it. Likewise, I have also learned there is an individually packaged vaccine available that does not have the preservative (mercury) in it that is safe for kids to get.

How would you like to die?

2009-11-01T03:24:00.000-05:00

A lot of people I talk to say if they had a choice they'd like to just drop dead so they wouldn't have to suffer. Not me. I want to know I'm dying. I want to die a long, slow death. I don't want to suffer, but people don't suffer these days. There are good medicines -- thankfully-- to prevent pain and suffering. but I want to have time to say good byes, to smell the roses and the fresh air one more time, to snuggle with my wife, to hold my daughters (or granddaughters if I'm old). I want to play catch one more time, to share wisdom, and to drain the writing well dry.

I think a lot of people would choose the easy way, the painless way (again, I don't think there has to be pain with all the meds available) to end it all, and I respect that. I understand why someone would choose that (not that we have the choice anyway). But I would like to choose the less popular route because for no other reason than I'd like to share the ride to tell the story, to write about the adventures all the way to the bright light seen down the tunnel that leads to the pearly gates and the promised land. I love life, and I want to absorb, to share, as much of it as I can.

And I suppose that's why I write in the first place.

Healthcare bill looks goulish and scaaaary

2009-10-31T11:27:00.025-04:00

(Editor's note: The following was written by Dracula while I was in that long dreamy trance. I'm still whoozy and my neck aches. )

Dear my friends (ahahahahahaaaaa):

I just got done sucking the blood of the RT Cave publisher (MMM!!! It was soooooo tasty!)

Now that he's out of the way I will take this time to voice my opinion about something that would make my blood boil -- well, if I had any it would boil.

I have obtained a copy of the healthcare reform bill released by the leadership of the U.S. House that merges all the versions of the bill passed thus far. This piece of work is expected to be "considered" by the full house next week.

The following are the major provisions of the bill and how it might effect you and other future sources of lunch (in blood red):

Expansion of health insurance to an estimated 96 percent of legal US residents under 65.
Individual mandate with penalties. (unconstitutional)
Employer mandate for those with payrolls over $500,000 with penalty (unconstitutional).
Subsidies for low- and middle-income families. (spreading wealth)
Medicaid expansion for families at or near poverty level Insurance reform (paid for by taxing people who have succeeded. This bill calls for a tax on insurance companies which will fall to the taxpayers by higher premiums, thus a tax hike.)
Ban on pre-existing condition exclusions. (a better way of doing this would be to give private insurance companies a tax break for taking the risk.)
Ban on rate adjusting based on pre-existing conditions or gender (this I like. Insurance companies could also get a tax break for taking on the increased risk, which is rewarding the risk takers).
Limits on rate adjustment, limited to age and family size.
Public Option with negotiated provider payment rates (check out this post. You ll learn the public option isn't so great after all).

Here's how the bill will be paid for:

$480 billion tax increase for singles $500,000/families $1 million. (Punish the achievers to the benefit of the have nots. This will be another disincentive for companies to take the risks needed to move up to the next income level)
$20 billion tax on medical devices. (which will be passed down to consumers, which are mostly the middle class who were promised no tax hike).
$400 million in spending cuts (mostly Medicare) (In a bill signed in the early 1980s, Congress promised to cut spending and never did. Can we trust Congress now. A recent poll shows 90% of Americans want all new Congressmen, a testament they don't trust the people who are responsible for this bill).

The bill also includes:

Medicare coverage of end-of-life counseling (described as "advance care planning" in the bill). (hHmmm??? What might this lead to)?
SSI eligibility exemption for clinical trials participation compensation - Improving Access to ..Clinical Trials. Expansion of Comparative Effectiveness Research.
Provisions to address healthcare workforce shortages. Physician payment "sunshine" requirements - but with an exemption for industry- sponsored CME ..activities.
Expansion of Medicare quality programs. Expands Medicare and Medicaid beneficiary access to preventive services by eliminating. cost- ..sharing. (Cost reduction is great, but can more easily be done by reducing regulations for private health insurance to improve competition)
Strengthening of the public health infrastructure through creation of a Public Health Investment ..Fund with authorized funding of $33 billion over 5 years.
Creation of a Prevention and Wellness Trust Fund for community-based prevention and chronic ..disease management with authorized funding of $34 billion over 10 years.

The basic premise of this bill is Congress doesn't trust private companies or people like the (tasty) publisher of this blog and you to do what is right, which is extremely scaaaary. They believe it's the role of the government to tell us what to do for your own benefit. Some people call this the nanny state.

I don't know about you, but this is enough to give even my lifeless bones the eebie jeebies. Just reading it sends a cold shiver up my dead spine. I don't trust your government with a ten foot pole. Sure your gov should have some power, but not this much. If this bill passes it will change the fabric of your lives. It'll be, excuse the pun, a pain in the neck to get rid of if it fails, if not impossible.

It should send a shiver down your spine too, especially considering the slippery slope that is bound to ensue in your neck of the woods. This post and this one describe this bloody, slippery slope.

Healthcare reform is needed, but not a government takeover. Better options would come from reforming the current system and letting people like you guys solve the healthcare problems that exist. Better options are on the table, as you can see by clicking here.

That's my take on it. Feel free to disagree.

Sincerely: Dracula

HAPPY HALLOWEEN!!!!!

Stepping Down

2009-10-30T10:20:00.001-04:00

(Editor's Note: This is a guest post from a senior RT at Shoreline Medical)

In 100 days I will be retiring from full-time Respiratory Care, I guess I'm just not sure how I feel about that. It is what I do best. Perhaps I should supply some history. In the late 50's (think polio), I wanted to become the next Jonas Salk, become a doctor, cure disease, that was me. Of course in the 60's women were discouraged from becoming anything but teachers, nurses or secretaries. In 1966 I entered a nursing program, hospital based, on site residency, and a whole different ball game than nursing is now. About half way through the program I knew that nursing as it was then was not for me. Nurses didn't get "no respect", were not allowed to think for themselves,and above all, the doctor was Divine, and I don't mean he was a hottie! So, I left the nursing program and went into data processing; talk about boring; so I dumped that too. I knew that I really wanted to be in medicine but what? I ended up going into cosmetology and cutting hair for a living. Then in 1979 I gave birth to an infant with severe meconium aspiration. He was an 8lb 12oz fighter who spent 29 days on a Baby Bird ( anyone remember those?).
I took him home with great relief and a huge respect for the respiratory therapists and neonatal nurses who took care of him.

I graduated from a nearby RT program in Dec. of 1984 and have loved every minute of respiratory therapy since. I've seen huge changes in the field, the phasing out of OJT'S, great advances in technology, respiratory therapy driven protocols, the demise of IPPB (that's for another post), and the bottoming out of reimbursement for services rendered. Now don't get me wrong about OJT'S, a whole lot of what I learned came from OJT'S, give me a good OJT with common sense anytime. Remember, you can't teach common sense and you can't fix stupid. Time has also taken away my junk box. Every old RT knows you have to have a junk box, afterall it's what RT's do, jury rig! If you need something, just dig into a box of old spare parts and adaptors and you'll come up with a serviceable device to do whatever job it is you need done. Ah, a sink trap, a couple of one way valves, a little tubing.........!

At an MSRC conference recently, I listened to a, shall we say seasoned, therapist talk about pulse-oximeters and end tidal co2 monitors. He said he smiles to hear today's therapists complain about having to carry the pulse-ox in their pocket! We remember when a pulse-ox was the size of a small suitcase, try putting that in your pocket!

What about pagers? I remember trying to decipher a mumbled overhead page in a patient room with the Price is Right blasting away at full volume. "Fresh and hairy come on down...to umph stat" or "code blue north..." north what for crying out loud. You just gotta luv those pagers and handy little phones we have now, or not. With two pages and one or two phones hanging off you, you can't hold your scrubs up!
Dropped a pager in the john once, gee, I hated explaining why it was all wet, "I don't know why it smells that way, just give me a new one and oh yeah, don't take that one outta the glove".

Oh man, don't forget ventilators. You like microprocessors, say they make your life easier, and wow, ventilator wave forms, self weaning modes, smart care? Well, I remember standing in front of an MA-1 with a stop watch! Anyone for an H valve? In a pinch, I can still use a Bird IPPB or a Bennett PR-2 for a ventilator, no bells and whistles and I can still save your life. After all, what is a ventilator? A machine that pushes good air in and lets the bad air back out, Emerson had it down pat, does anyone besides me see the correlation between peep on an Emerson and Bubble cpap for neonates? There is nothing new under the sun, it is all slightly used, ie; non-invasive ventilation. I'm expecting a resurgence of IPPB, modified maybe but IPPB all the same. Let's see, tack on a couple of high tech monitors, paint them blue, gray or cream, change the name and jack up the price. Don't laugh,it happens all the time! Just promise me this, when all the old RT'S are gone, all the high tech equipment fails, please tell me that you youngsters can still look at a patient and know something is wrong and what to do to fix it based on good patient assessment! Is he breathing, does he have a pulse, is he pink warm and dry or blue cold and clammy? What is the most important thing to do first?

Let's not forget the drugs; we've come a long way since Isoproterenol and epinephrine. My favorite nebulized medication is Ativan, I want to have it nebulized through our ventilation system here at Shoreline, along with vats of Albuterol, otherwise known as Do-allolin. Oh well, that's going to take a little more convincing.

So, back to retirement, I'll still work, do a little relief here and there, someone has to make sure that all you youngsters are doing things right.

Thanks, Plain Old Jane

The most sagacious RT I've ever met

2009-10-30T03:15:00.009-04:00

I'd hate to give her an ego boost, but one of the main reasons I decided to work at Shoreline Medical was because of Jane Sage. She's one of the most easy to approach people I've ever met. She's also full of RT wisdom. You can ask her any question and she'll have an answer with the snap of a finger.

It's that kind of wisdom I wanted to obtain, and for that reason I sort of adapted her as my mentor whether she knows it or not. In fact, I think everyone in my department has adapted her as a mentor. So what is a mentor. A mentor is a person (or ghost if you like Shakespeare or ancient folklore) who teaches wisdom to make you the best person you can be.

She's one of those people anyone is comfortable talking with. And even during the most stressful periods her deportment is always cool, calm and collect. And it's not just me who's impressed by her wisdom and deportment, it's everyone in my department if not the entire hospital.

When I first started working here she made it clear I could call her even during the wee hours of the morning. I took advantage of this on many occasions, even recently.

One of the first times I called her was when my first really bad asthmatic patient was admitted, and the doctor wanted her on a 700 tidal volume. All the RT wisdom I learned from RT school was shouting at me this was waaaaay too much for this patient. I was stressed because the doctor was breathing down my back while I was looking over the vent, which was alarming like crazy. The patient was fighting the vent big time. She was autotrapping. I had her on a tidal volume of 200 and that was with a pressure of 58. Even though I was fresh out of school, my gut feeling said that there was no way I should give this lady more than 200. Yet how was I, a rookie, going to tell this to the experienced and arrogant doctor.

Yes I was second guessing myself as many new RTs do, so I risked looking like an idiot to the doctor and stepped aside and called Jane. She answered the phone with her usual pleasant tone and provided some options to me. Right away she made me feel better about myself and my decisions.

Finally she decided she would come in. This turned out to be a great thing considering Jane never left the patient's room all night, and neither did the doctor. I was so thankful that she came in because ER was also swamped that night. She did not have to come in. She was not even on call.

The next time I saw Jane she said she explained to the doctor pretty much what I had already told him. I suppose he just wanted to hear the wisdom from a seasoned RT as opposed to a rookie. I quickly realized Jane had the answer to not just every RT related question, but to RN related questions as well. In fact, there have been many occasions where even doctors called upon her for her wisdom -- even calling her at her home.

Later Jane told me that I impressed her that night as well, and not just because of my gut instinct to follow the wisdom I learned in RT school, but because I bit my pride and got on the phone to call her. She'd make a good politician because she knew exactly what buttons to push.

I've had the privilege of following Jane for 12 years now. That's 12 years of watching her work, and listening to her wisdom. We've had discussions on nearly every topic from RT Wisdom to politics, from discussions about paleoconservatives to Aragon. There aren't many people around who enjoy an intelligent discussion regardless of the topic.

In fact, I can honestly say that she alone was the inspiration for me to be more than a button pusher respiratory therapist. I could have been paired up with a lazy RT, or a complainer, or someone who was just satisfied with getting a paycheck and doing as little as possible to earn it. Yet, thankfully, I was paired up with Jane, who was always striving to become a better RT; always researching; always learning; never satisfied with the status quo; always questioning; always thinking.

She is not nor ever was an RT boss, although she easily could have been. She ran the department per se but not really. She was a true leader who had plenty of wisdom to provide to the RT bosses in times of crisis, and when it came to creating new policy, or writing new protocols, or convincing doctors they were wrong or that changes were needed, Jane was up to the task.

I know that Jane spent hundreds of hours writing a ventilator protocol once, and then it sat in her locker collecting dust for probably 10 years. In this time several other protocols were written and rejected. Yet, while the other RTs gave up, Jane charged forward. Despite the low morale, despite the reluctance of the admins and RT bosses to change the status quo, Jane never stopped learning, never stopped creating.

Then one day a doctor went to the RT Boss saying that he thought it would be a good idea to have a ventilator protocol. The RT Boss directed this doctor to Jane who just happened to have a protocol in waiting. The doctor was impressed, and now that protocol has been in effect for five years. Of course that doctor took credit for the protocol, but Jane didn't care. Jane's persistence was rewarded. In fact I think just yesterday on this blog she wrote about the importance of being proactive in her advice to newbies.

I remember once driving down south to a nice restaurant where a representative of Xopenex was going to give a presentation. After several free drinks, a delicious free steak dinner (of course we ordered the most expensive items on the menu), and a buzz, Jane listened as a pediatrician asked about the use of Xopenex for his pediatric patients. Jane said something like, "Do you guys have any research regarding bronchodilators and RSV. I've read that the latest research shows that bronchodilators aren't recommended for RSV anymore. Is this true?"

I can't remember what the reps answer was, nor does it really matter. What I remember most is what Jane said to me on the way back: "You see, Rick, I was just planting seeds. That's the best way of changing doctor's minds. You do it by first planting seeds."

Later I learned that she was really good at convincing doctors to do things her way by making the doctor think it was his idea. This was perhaps one of the best skills I've picked up from Jane. You just kind of slip an idea into the doctors mind, and let him take credit for the idea. That's the way we RTs function.

Sure there have been ups and downs in the morale department, and there have been turnover of bosses, admins and nurses. Yet through it all this hospital has always seemed to have a good feeling about it. In fact, when I first started working her I remember telling Jane that I thought it was neat how well the nurses here get along with the RNs so well. Jane said to me, "This place has kind of a down home feeling about it."

She was right. This place is a great place to work. Sure there's always politics, but overall Shoreline medical is a down home place. And one of the reasons for that is people like Jane Sage with her pleasant deportment, her never get angry deposition, and her willingness to learn and share her wisdom.

She can take a joke, too, as well as dish one out. One day I came into work to learn that there were 25 patients, three vents, and that I was going to have to work alone. And just as set out to tackle this dilemma with my vexed heart racing, she said the magic words: "April Fools."

I can't imagine what Shoreline Medical will be like without Jane. She's the kind of worker no boss wants to see move on, and no coworker either. Yet, as with all good things in life, there comes a time for it to end. Tomorrow, right here at the RT Cave, Jane will announce her retirement.

Note #1: Shhhh!!! Just between you and me, this will be good for the RT Cave because she'll have more time to write for us. I'm sure we could all benefit from the wisdom of the most sagacious RT: Jane Sage.

Note #2: Calm down Jane. Don't get too big of a head. If your ego gets too big your head will expand and you'll become a doctor.

Some Sage advice to the Newbies!

2009-10-29T07:36:00.001-04:00

(Editor's note: This is a guest post from a senior RT at Shoreline Medical)

As I continue to contemplate retirement, I worry about what will happen to all the advancements at Shoreline, that I have been a part of over the years. These advancements are hard-won, hard fought for victories that I am particularly proud of. I couldn't enumerate or name them, as they have accumulated over a twenty five year period. I worry even more about advancements of my profession here, if someone doesn't step up to the plate and take over my pro-active stance about the place of respiratory therapy at Shoreline.

When I arrived here as a rental therapist 25 years ago, I had only been in the field for a year and was the typical cocky, know it all, coming to Podunk from a much larger teaching hospital where I spent most of my time in the post open heart unit. Therapists here did not get a lot of respect from the doctors or the nurses. They were looked upon more as aerosol and oxygen jockeys and much less as professional, educated patient care givers. They were most definitely NOT a valued part of the patient care team. I would like to say that I immediately set about fixing this nasty little perception of who we were, alas, that is not how it went.

After my first three weeks, I had managed to upset and alienate at least half of the nursing staff and a couple of doctors. I'm not sure my co-workers or my director really thought I would ever fit into the establishment. I started and ended many conversations with, "Well, at Mid-Regional Hospital we did it this way". Needless to say this did not go over well at all. I finally came to realize this when one of the nursing staff looked me square in the eye and quietly said, "If it was so much better at Mid-Regional, why don't you go back there!" I was completely stunned! Why would she speak to me in such a fashion? Thankfully I was able to figure out the problem, it was me. After much soul searching I was able to see the error of my ways and was able to accept there was no one way to approach a single problem. Thanks to that nurse I was able to grow and become a better person and therapist. I still work with this woman and have been happy to do so all these twenty five years. Moral, be open minded, willing to listen and above all, a team player.

I have also learned that tho' you may lead a horse to water, you can't make him drink, is not true, with a little patience, you may lead that horse to water and waiting long enough that little bugger will get thirsty and finally drink. Moral, if you want to make changes, present the ideas, be prepared to defend them and someone will start listening. You may not get all that you ask for but like any good salesman you have now got your foot in the door and time will do the rest.

Here at Shoreline Medical the Respiratory department has been complimented and held up as an example of continued learning and expertise. Within the ranks of our staff there is a constant drive to be the best we can be, (is that a Marine axiom?). We have shadowed staff in the NICU's, MICU's and TICU's of large teaching hospitals in our area. This took some co-ordinated effort on our part and the part of the teaching institution but it was well worth it. At smaller rural hospitals you, as a therapist may never encounter certain aspects of critical care/trauma, but if you do you must do the right thing at the right time and that means being as familiar as possible in these areas. Moral, learn, learn, learn.

A few years ago Shoreline implemented the Michigan Keystone ICU. Accidentally, I came up the announcement of meetings where a ventilator protocol would be drafted. Now I had been singing the protocol song for a long time and had many of my own ideas of how one should be written. Not having been invited to the Keystone meetings I hurried off to my directors office to beg him to volunteer me for this committee. Thankfully, it worked and our department was represented in this most important area of our field. Moral, knee jerk reactions are too late and a dollar short. Be proactive not reactive! If you don't participate don't b""""".

Probably the most cherished complement that I have ever received was one that came from a patient's husband to my director, "Jane is an example of the consummate professional". I cannot begin to tell anyone how great that made me feel. I still see this man around the hospital today and always become conscious of who I am and who I represent to the patients, family and other staff members. Moral, to be treated like a professional, you must first act like a professional. I sure hope the man meant the statement in the manner in which it was received, otherwise that plump feather in my cap will surely be plucked!

Here's 33 reasons you'll want ot be an RT

2009-10-27T10:03:00.000-04:00

So you're thinking about being a respiratory therapist. Here are 20 reasons this is the right profession for you:

You want to work in the medical profession but you don't like poop.
You don't mind working with spit and goobers.
You enjoy a good conversation.
You have a good sense of humor.
You have a friendly disposition
You get irritated easily with stupidity.
You have the grit to keep your mouth shut when your wisdom is not wanted
And the courage to speak up when your wisdom will help a patient.
You can handle being on your feet for 12 hour shifts.
You like flexible hours and lots of days off.
You like the rush and challenge of a cardiac or respiratory arrest.
You can handle seeing bones and brains and at least tolerate bagging over vomit.
You enjoy the satisfaction knowing what you did gave someone a chance.
You enjoy the rush of a busy emergency room.
Or the challenge of making a critical decision
Or working with complicated breathing machines
You enjoy learning new RT Wisdom.
You like drawing and interpreting ABGs.
You don't mind doing EKGs (usually a job of RTs at smaller hospitals)
You enjoy working with nurses and doctors to the benefit of the patient.
You love educating patients.
You can handle being swamped one minute and slow the next.
You don't get frustrated every time your beeper goes off.
You can handle talking with frustrated or irritated physicians
You like having time to surf the Internet.
You like eating three meals while getting paid
and you enjoy eating candy bars, cookies, cakes and other treats
You want a recession proof job
You want a job that is easily portable
You like having the freedom to roam entire hospital
You enjoy gossiping.
You like watching TV while working
You like blogging and playing on Facebook or Twitter.

RT profession growing and gaining respect

2009-10-26T02:33:00.001-04:00

It's RT Care Week! It's time to reflect on the fact we are leading the charge to improving a profession that is still in its infancy. We are, as they say in sports, not rookies, but not even in our prime yet. We are, as they say in fantasy sports, the sleepers, the prospects with a lot of upside.

You'll see your friendly neighborhood respiratory therapist walking room to room giving breathing treatments, participating in friendly discussions, and cheering up overworked and exhausted nurses and sick patients with their dry humor.

Yes we are an interesting bunch. Some of us grumble and gripe at each new stupid doctor order. Some of us are cheerful no matter what. Some of us are the kings and queens of hospital gossip. Some of us trudge from room to room without saying much of anything.

Yet, no matter what personality RT is taking care of your patient area, you should always know your RT is available to lend a helping hand. If you need an extra body to boost a patient, your RT will be there. If you need help holding down a child for his daily lab draw, your RT will be there.

You also should know that any time you walk into a patient's room and the patient just doesn't look right, that you should always call your RT. He might look at the patient and say, "Oh, he looks fine," or he may say something along the lines of, "I think this patient is wet. It is my humble opinion he might need Lasix. Let's check the i's and o's, though, before we call the doctor. Perhaps we should also get vitals so the doctor doesn't get mad because we don't have all this information available."

This great profession has come a long way since the day of the OJT; since the day when RTs were nothing more than button pushers, or ancillary staff. Yet, while many physicians, nurses and RT bosses have grown with the RT profession and learned to trust the opinions and expertise of the now well trained through qualified RT programs, continued education and experience RTs, there remain many still stuck in the past who still think of RTs only as an ancillary service.

Yes, even recently I have seen both sides of this coin. I have gone down to the ER, seen a patient in respiratory distress, made the appropriate decision based on my 11 years of experience as an RT and 38 years of experience as an asthmatic, and the patient benefited as a result.

When I was finished, I approached the ER physician and informed him of what I did. He enthusiastically said, "Great job! Thank You! I love it when you take charge! You did a great job!"

I was riding high. I did not grow a big arrogant head by no means, but it felt so nice to have a physician not just respect this profession, but to realize how we can be part of the team, and because he actually told me how well he respects me.

It made me feel good because recently I started an Albuterol treatment on a patient I suspected of being in bronchospasm, and the physician working the ER that day said, "What is this?"

"The patient's short of breath and his lungsounds were diminished," I said.

"Well, we don't start breathing treatments without talking to me first. I'm the doctor and that's my job."

I was beside myself. I took the nebulizer from the patient and dumped it into the sink. If this was a rude thing to do, I wasn't thinking of that. I wanted to simply give up. I wanted to take my brain filled with RT wisdom and go home. I wanted to quit.

But I didin't. I swallowed my pride and stood there feeling like a five foot fifth grader standing in the principal's office waiting to be scolded.

The physician turned to me and said, "I want Xopenex and Atrovent."

So, while this profession was once seen as 100% ancillary and 0% professional, it is now seen as ancillary about 50% of the time and professional about 50%. It basically depends on what nurse is working, and what physician is working.

This is progress. This is good. Yet, while the nursing profession is seen as a well respected profession, the RT "profession" is still lagging behind -- yet growing.

My advice to aspiring RTs is this. If you are looking to be an RT, go for it! This is a great profession and you and I can be part of the effort to driving this profession into the future. The RN profession was once in its infancy and through the years physician's learned that by respecting RNs not only do they benefit, but so to does the patient.

The same will hold true with the RT profession, only we who are presently working in the field have a unique ability to shape it into the form of our choice. So, if we stand by and let stubborn physician's pent on holding onto the past shape this profession, they will define our future.

Yet, if we stand firm, be patient, step forth, and continue to voice our opinions in a professional manner, we will shape this profession into the mould of our choice.

Yes, this is a slow, humble, and political process. It's changing the mind of one RN, one doctor, one RT, one RT boss, one administrator at a time. But we know it can be done. We know this because, as Jane Sage wrote in a recent post, the RT profession has already grown since the days of its infancy.

Sometimes I think we RTs are underutilized. Sometimes this irritates me. Sometimes it makes me feel apathetic. Yet, I also know there are many nurses who call us every time they suspect something is wrong with OUR patients. They know that we are specially trained in an area they glossed over in RN school, and they highly respect our opinions.

I recently overheard one sagacious long-time RN say to a student: "Don't be afraid to call RT. They have saved me many times."

We assess patients. We have listened to so many lungsounds that we might just be better than physicians at noticing little trends, at noticing early pneumonia, CHF, pulmonary edema. "This patient is wet!" The RT might say. "You need to call the doctor right away!"

Or, perhaps the RT was not called when the patient was blue around the lips. The nurse who held onto the old-school belief of RT as an ancillary service may have called the physician panicky. The doctor would order an ABG and write an order for more oxygen.

The nurse who learned to respect the RT on duty called the RT, and said, "The patient is blue, and I just wanted your opinion before I called the physician."

On a whim the RT enters the room and checks to make sure the oxygen is still on and connected. As it turns out his whim turns out to be a good idea, because the oxygen was on but disconnected. Once the problem was fixed the patient pinked up. The nurse was ecstatic, and never had to call the physician. We are a TEAM. What one of us doesn't pick up the other does.

Yes, you can see that we RTs, doctors, and RNs are part of the patient care team. Like RNs, we are not only well educated, we are licenced professionals. We are trained to assess, evaluate, think and communicate. We are not physicians, we are not nurses, and we are RESPIRATORY THERAPISTS.

We are part of the patient care TEAM!

It is now RT Care Week, a time to reflect on a profession that is still in it's infancy and growing in every area. We need to feel proud and joy in all we do, and we certainly hope RNs, physicians and admins appreciate what they have by the RTs working around them.

The most important aspects of life

2009-10-25T05:28:00.003-04:00

The religious say you don't need material items to be happy in life. They say those who are rich and who continue to seek more wealth and material items are the least happy. The older I get the more I value that old wisdom.

As an RT I'm not able to provide much for my family, at least not as much as some of my neighbors. While I have a great family in a nice new neighborhood, I can't afford a new camper, 2 new motorcycles, a huge camper, a new lawn and monthly fertilizing of it, the best toys for my kids, daily golf outings, and yearly upgrades on my house.

I have none of that. I'm not saying I don't want it all, but I can't afford it unless I packed it all on my debt. However I've been advised against that.

I'm not saying I'm taking the frugal route because I'm religious, because I'm certainly a flawed person (aren't we all?). But it is the religious who will say it's funner, wiser, and better to take the frugal route for no other reason than it teaches you to appreciate and value the most important assets in life -- life itself and people.

Perhaps this is why you'll see this humble RT lying on the front lawn on a blanket with his baby absorbing not rays because his daughter cannot be exposed to the sun yet, but simply the time well spent enjoying the warm weather and appreciating not just the weather but the wisdom of a good book. And, most important, time with the wife and children.

After all, no one on his death bed wishes he purchased more stuff. And one rarely hears one saying he regretted time well spent appreciating the most important aspects of life.

Determining level of consciousness

2009-10-24T04:07:00.000-04:00

This is pretty much RT 101 stuff, but the following are the various levels of consciousness one might observe of others. A wise RT will be familiar with these terms and use them accordingly.

Lethargic: somnolence: sleepy
Stuporious: confused: responds inappropriately, OD, intoxication
Semi-comatose: responds only to painful stimuli
Comatose: does not respond to painful stimuli
Obtunded: drowsy, maybe decreased cough/gag reflex

Indications for intubating neonates

2009-10-23T04:06:00.001-04:00

The following are the indications for intubating a neonate:

PaO2 less than 45mmHg while breathing 80 – 100% FiO2
PaCO2 greater than 65mmHg
Intractable metabolic Acidosis(B.E. less than -10 meq.)
Marked retractions on CPAP
Frequent episodes of apnea and bradycardia on CPAP

How do RT departments make money?

2009-10-22T03:00:00.004-04:00

How do RT departments make money? To answer this question, I think I'll take a backward step and ask a slightly different question: How do hospitals make money?

Unless the patient is paying out of pocket, the admitting diagnosis is what determines how much money the hospital makes on a particular patient visit. According to "Egan's Fundamentals of Respiratory Care," each patient is designated a specific Diagnosis Related Group (DRG) based on the diagnosis.

The Healthcare Financing Administration assigns a set reimbursement for each DRG. Thus, according to Egans, "Because the amount remains fixed for each admitting diagnosis, hospitals know in advance exactly how much reimbursement they will receive... Hospitals that can provide care for less than the fixed rate can keep the difference, thereby realizing a 'profit.'

"On the other hand, hospitals whose cost of care exceeds the fixed rate must absorb the cost and thus take a financial loss. By placing hospitals at risk financially, this system provides a powerful incentive for cost efficiency."

The best way to cut cost is to use the fewest procedures needed to make the stay as short as possible.

This in mind, the RT department really doesn't make any money off the therapies it does, unless those therapies get the patient better and fast.

Now, considering I believe that about 80% of the bronchodilator breathing treatments we do are not indicated, it's amazing to me that no one ever cracks down on this. I imagine what keeps this RT Cave intact is the RT Cave bosses not allowing admins to catch on to this in order to keep the procedure count up in order to keep your humble RT on the job.

So, how do RT departments make money? I don't have an answer to that. Do you?

Can Advair & Spiriva be taken together?

2009-10-21T04:35:00.002-04:00

The following question and answer is from a Q&A session at the HealthCentral network.

Question: What is the point of taking Advair and Spiriva together?

My humble answer: Great question. They are both preventative medicines. As you know every person is unique, and one person's asthma may be more difficult to control than another person's asthma. Therefore, it is the job of the doctor to work with you to find the best concoction of medicines to control your asthma.

There are basically your usual front line medicines that are recommended to treat asthma, and your second line medicines that aren't usually needed but sometimes can help control asthma. Advair is a front line medicine because it usually works fine by itself to get asthma under control. If, on the other hand, Advair alone isn't getting the job done, your physician may resort to trying second line medicines like Spiriva.

That said, Advair has both a corticosteroid (Flovent) to treat the underlying inflammation component of asthma, and long-acting bronchodilator (serevent) to prevent the bronchospasm (airway narrowing) component of asthma. Serevent is a beta-adrenergic medicine that causes bronchodilation (relaxes smooth muscles). It attaches to beta receptors in the lungs, and when this happens the lung muscles relax.

Spiriva is a long acting bronchodilator that works by blocking cholinergic receptors in the lungs that cause bronchoconstriction (airway narrowing) when stimulated. Thus, Spiriva is an anticholinergic medicine. In this sense, it is often referred to as a "back-door bronchodilator." It is not as good of a bronchodilator as Serevent, and therefore is a second-line therapy for asthma.

Recent studies, however, do show Spiriva improves lung function in COPD patients and some difficult to control asthma cases. Therefore, if front line asthma medicines like Advair do not control asthma, Spiriva is a good medicine to "try" in conjunction with the recommended front line medicines.

Of course, there's always the chance your doctor has a different reason for prescribing both Advair and Spiriva for you. Therefore, it is always a good idea to talk to your doctor so you are on the same page with him or her.

For more information, click here and here.

What happens to cause asthma?

2009-10-20T04:18:00.000-04:00

Question: what in the body happens to give you asthma? I have to do a report for school.

My humble answer: You've come to the right place to find everything you need to know about asthma. The best place to start is by clicking here or, better yet, here. By following these links you should get a good overall understanding of what asthma is and what "triggers" an asthma attack and what an asthma attack is.

No one really understands what causes a person to develop asthma in the first place, but there are theories, such as this one I wrote about.

The airways of most asthmatics are always inflamed (swollen) to some degree. Depending on the severity of this inflammation determines how bad one's asthma is and how sensitive the air passages are to asthma triggers.

When an asthmatic is exposed to his or her asthma triggers, this triggers the asthma response you can read about in the second link above. This ultimately leads to the air passages in your lungs (check out this link) to become increasingly inflamed (swollen) causing them to constrict (become narrow).

When this happens air you breath can enter your lungs, but the narrowed airway traps the air in your lungs (this is called air trapping). Since an asthmatic during an asthma attack has this extra air in his lungs, it feels as though he can't get air in, but the truth is he can't get air out. He then feels like a fish out of water.

Fortunately there are medicines to treat an acute (ongoing) asthma attack like this and even more medicine to prevent an asthma attack. You can read about asthma medicines here.

If you want to read a very thorough writing about what asthma is, you should check out the asthma guidelines I will link to here. Actually, the answer to your question should be in this section.

Good luck.

Setting up ventilator on neonate

2009-10-19T04:02:00.005-04:00

Guidelines for setting up a Neonatal Ventilator:

1. Patient range: Set to neonate (Maximum VT = 40cc)

2. Mode: Pressure Control (works best for un-cuffed ETT)

3. Tidal Volume (VT)*:

less than33 weeks gestation 4 – 6 cc/kg
greater than33 weeks gestation or chronic 5 – 7 cc/kg

4. Peak Inspiratory Pressure (PIP)*:

less than27 weeks gestation set at 24 CWP
27 – 32 weeks gestation set at 26 CWP
33 – 40 weeks gestation set at 28 CWP
Start low (best to err on low side to prevent barotraumas.)
Increase to obtain target VT and adequate chest rise
Frequently monitor & adjust PIP to accommodate changes in lung compliance altering tidal volume.

5. Positive End Expiratory pressure (PEEP):

Start at minimum 4 – 5 CWP
Increase to 6 – 7 CWP if FiO2 needs greater than 60%
Adjust to maintain acceptable PaO2 and SpO2
8 – 10 CWP PEEP if directed by physician
Remember that Pressure Control (PC) setting is “above PEEP”

6. Fraction of Inspired Oxygen (FiO2)**:

Start low at 40%
Adjust to maintain target SpO2
If SaO2 less than target range, FiO2 may be increased by 2–5, & then allowing 4 minutes for stabilization after each change. (consider adjustment of PIP and PEEP also.)
Continue assuring AW patent, HR greater than100 & baby not apneic.
If SaO2 greater than target range, FiO2 may be decreased by 2 – 5,
allowing 4 minutes for stabilization after each change.
Consider increasing PEEP prior to FiO2
Maintain neonate on ROOM AIR whenever possible.

7. Rate:

50 – 60 if less than 34 weeks gestation or less than 3 kg
40 – 50 if greater than 34 weeks gestation or greater than 3 kg
30 – 40 if 40 weeks gestation; slightly higher if indicated.
Watch for air trapping at rates greater than 40 (adjust I-time).

8. I-time:

Start at 0.3 plus or minus 0.5 (post-term may need more.)
Neonatal initial I-time setting
less than 1kg 0.25 – 0.30 sec minimum 0.20 seconds
1-2kg 0.30 – 0.40 sec minimum 0.20 seconds
2-3kg 0.35 – 0.45 sec minimum 0.25 seconds
3-4kg 0.40 – 0.60 sec minimum 0.30 seconds
Ideally set using Flow-time graphics
This alters I-time and I:E ratio
Increase & decrease to reach target settings as appropriate
Watch for air trapping at rates greater than 40 in neonates greater than 3kg; they may need I-time greater than 0.40 to complete inspiration & prevent air trapping.
If neonate using expiratory muscles, try decreasing I-time
slightly (increasing flow).
If I-time gets too short, consider switch to PRVC.

9. I-Rise time:

10 if less than 33 weeks gestational age
greater than 5 if greater than 33 weeks gestational age
Basically, the smaller the ETT the higher this should be to
create laminar flow and a pseudo sign wave.
Increase for bronchospasm (slow rise time, longer e-time)

10. PIP limit: 2 – 3 greater than PIP (all other alarms as appropriate.)

*Note: Higher PIP and VT may be needed in certain cases. Consult physician if unable to ventilate at recommended settings. Settings may also be unique to particular ventilator, guidelines, or protocol.

**Note #2: New studies show that high levels of oxygen, even in term babies and even for periods of less than a minute, can result in long term consequences to the child such as Retnopathy of Prematurity. Proper ranges to strive for will be the topic of a future post.

Note #3: The above information may be slightly different for your institution and the equipment available, yet the principle remains the same regardless of where you work.

For a cheat sheet with the above information, click here.

Thoughts of living long

2009-10-18T05:06:00.002-04:00

When my 1-year-old girl is 40 I will be 80. And I think how fast my 40th birthday is approaching (I'll be 40 in January). That 80 years will be here in a heartbeat.

I think I want to be here to lend a hug and an ear to not just my daughters and son but my grandchildren. I imagine I'll have some by then. Perhaps that's the greatest incentive to eat well and exercise and live well.

Perhaps I ought to print this post and tape it to the fridge so I can be reminded of this incentive daily, because it sure isn't easy to eat right, exercise and live well.

I mentioned this to my dad who is 66. He said when he turns 80 his youngest daughter (my sister) will be 40. So, dad is in the same position in a way as me. The only thing is, when I turn 80 my dad will be 106.

I wonder if we'll be in the same nursing home by then. That wouldn't be so bad, because my dad's pretty cool. He seems to always know how to find fun. Perhaps his daughter and granddaughter can visit us regularly.

Inhaled steroids don't cause pneumonia

2009-10-17T11:53:00.002-04:00

Aha! Another fallacy debunked. Well, surely we are aware that this is one study, but the results of a recent study confirm that inhaled corticosteroids like Flovent or Pulmocort, or combination inhalers like Advair and Symbicort, do not cause pneumonia.

Yet, it is true that pneumonia is common among COPD patients, however the reason is not because these individuals are taking steroids. And sure steroids can knock down the immune system in your mouth slightly, thus causing thrush. Yet this minor side effect can be almost completely "washed" away simply by rinsing after each use.

Advair is said, according to most studies, to not cause any systemic side effects -- so long as you (ahem) rinse after each use. Thus, what causes pneumonia is not the inhaled steroids, but something else. Perhaps it's the fact that many COPDers have excessive phlegm trapped within their lungs, which creates a breeding ground for bacteria. This, I would suspect, causes most cases of pneumonia in COPDers.

The fact they are taking an inhaled steroids to reduce inflammation and prevent bronchospasm is not what is causing pneumonia. In fact, there have been many COPD patients over the years who were not on inhaled steroids, and they were equally likely to have pneumonia.

So, fallacy debunked? Perhaps. While we have common sense enough to know this is just one study, we also have common sense enough to not believe every little rumour about a new medicine that comes around.

The truth is, there are many people who don't take medicine their doctor prescribes to treat their lung diseases out of fear of side effects from the medicine. As an asthmatic and a person who's used inhaled corticosteroids for over 30 years to treat severe asthma, I can honestly state that the risks of not taking your COPD/asthma medicine are far worse than the risks of the medicine itself.

In fact, I think we ought to make this RT Cave #38:

RT Cave Rule #38: The risk of not taking asthma and COPD medicine is far worse than the risks of the medicine taken to treat these diseases.