I was talking with one of the Asthma Research Recruiters over at the NIH in Bethesda Maryland where I’ll be involved in a study later this year( more about that in a future post), and I was shocked to learn that they were having a really hard time getting volunteers for there asthma research projects, especially those with severe asthma.

Here’s the deal… asthma isn’t gonna go away anytime soon on it’s own. If you suffer from this disease and you want to improve the odds of having better treatment options available to you during your lifetime, you should seriously consider becoming a clinical research volunteer for an asthma research study or clinical trial in your area ( or if you’re adventurous like me, out of the area).

To make it easier for you, I’ve listed 4 of my favorite clinical trials search engines to get you started.

1) Clinical trials.gov

2) Research Match

3) Medpedia

4) Trial-X [You'll find a handy little search tool on my sidebar]

While searching for a study that interests you, ask yourself these questions:

* What is the purpose of the study?
* What is required of me?
* What is my role in the study — am I a healthy volunteer or a patient volunteer?
* Will the study directly benefit me?
* Will the study benefit others?
* Are there risks? If so, what are they and what are the chances that they will occur?
* What discomforts are involved?
* What is the total time involved?
* Are there other inconveniences?
* Have I discussed participation in the study with those who are important to me, such as family and friends?
* Do I wish to participate in this study?

We need to put and end to the suffering that this disease causes. There’s a lot of promising research going on right now, but they can’t go forward with without human test subjects. I know it’s hard to find the time required to get involved, but many of these studies will reimburse you for your efforts….some will even pay for your travel expenses. If you have moderate to severe asthma and can travel, you might also consider SARP at the University of Pittsburgh or one of the asthma studies conducted at the NIH.

Thanks for your help!

New for this year I’m introducing a new a feature I call “USE ME”, where I answer your questions relating to respiratory therapy, asthma, lung disease, fitness walking or just about anything else you think I might be able to answer in the form of a blog post. The only caveat being that I can’t diagnosis specific medical medical conditions.

What makes me such a know it all in these areas?

Well, I’m a licensed and registered respiratory therapist of 33 years, a life-long severe asthmatic, a sought after lab rat and a 7 time marathoner finisher. I’m also pretty good at explaining medical/technical things in a way that non-medical people can understand.

So cmon, what are you waiting for. Take advantage of me, pick my brain…USE ME !!! I’m sure there are questions you’ve always wanted to ask . No question is too silly.

You can write me privately with your questions or leave them in the comment section. I’ll try to answer as many as I can and post them here on a bi-monthly basis.

Incidentally ….Do you know what the most common Google search phrases are that brings people to my site? #1 is “Hospital Bills” followed by “Recovering from severe asthma exacerbation” . The most searched image from my blog is a photo of me gorked out on Propofol while on the ventilator.Go figure

“ABG’s” is another one of those medical acronyms that you hear all the time when you have asthma or lung disease. And if you’ve ever been unfortunate enough to be hospitalized for your asthma, no doubt you’ve had one of these tests done on you.

ABG stands for “Arterial blood gases”. An ABG is a blood test that measures the PO2 (oxygen) and PCO2 (carbon dioxide) in arterial blood ( blood that comes from an artery vs a vein). The Ph (the acidity/alkalinity of the blood ), HCO3 (Bicarbonate buffers) and SAO2 (O2 saturation) are also determined.

The test is performed by collecting a small sample of blood from a peripheral artery (not a vein) usually in your wrist where you feel your pulse. Because you can’t see arteries, the person drawing the sample has to go entirely by feel, which means it can often take more than one poke to hit the blood vessel ( and yes…it can hurt like crazy too).

ABG’s are usually only obtained on asthmatics who are experiencing severe respiratory distress and are not responding well to treatment. Because ABGs can only indicate a persons breathing status at that particular moment, they are often repeated several times during the course of a hospitalization. Patients who are in critical condition and who require frequent ABGs will usually have a special catheter inserted into the artery (called an Arterial Line). Whenever an arterial blood sample is needed, it can be drawn directly from a special port on the catheter instead of having to poke the patient with a needle every time.

Normal ABG values would look something like this:

Ph 7.35-7.40 PCO2 35-40 PO2 80-100 HCO3 24 O2 SAT 97-100%

All 5 of these parameters are used in evaluating the respiratory status of a patient, but for the sake of this discussion the value we’re most interested in is the PCO2 (carbon dioxide). CO2 is a waste product of cellular metabolism and because we get rid of it by exhaling it out of our lungs, measuring how much CO2 is in our blood gives us a good indication of how well our lungs are doing their job. The faster and deeper we breath, the more CO2 we expel (we call this “Hyperventilation”). The slower we breath, the more CO2 we retain (we call this “Hypoventilation”). During normal breathing, the body maintains just the right level of CO2 (35-40)

Here’s a scenario of what can happen to your CO2 levels during a severe flare;
During a severe asthma attack it becomes very difficult to breath. As a result, you’re forced to use more breathing muscles than you normally would (what we call accessory muscle use) in order to get the air in and out of your lungs. This extra muscle use causes more CO2 (waste) to be produced. Ever notice that you breath faster during an asthma attack? It’s not only from air hunger. The body’s first line of defense against rising CO2, is to breath faster in order to blow it off and keep the levels within a safe range. However, if the work of breathing gets too severe, the lungs are unable to expel the CO2 fast enough and blood levels continue to rise …we call this “Respiratory failure”. The work of breathing can become so overwhelming, that the person begins to tire out and could eventually stop breathing all together… we call this “Respiratory Arrest”. Hopefully this will never happen to you.

Too much CO2 can make the blood very acidic (decreased Ph). If the CO2 blood levels get too high or the Ph too low, it can cause damage to the vital organs such as the brain and heart. As a second line of defense the kidneys will hold on to more sodium bicarbonate which helps buffer the extra acidity.Bladder activity is also increased to help get rid of the acidic compounds. The problem with this 2nd line of defense, is that it takes much longer to kick in.

One way we can quickly the lower CO2 in someone who’s in respiratory failure, is to blow the CO2 off by mechanical means…either with BIPAP or a ventilator. By placing someone on a ventilator, we can control how much air moves in and out of a persons lungs thereby regulating how much CO2 moves out.

The example above, is of course an over simplification of what can occur during a severe attack. There are many other factors involved, but the basic goal in treating a critically ill asthmatic is to open up their airways and normalize their blood gas values.

Here you can see an arterial line in my left wrist and some bruising from previous arterial line attempts in the right arm.

As a Respiratory Therapist Ive done thousands of ABG’s on patients, and as a severe asthmatic myself, Ive had hundreds of them done on me. Here are some of my actually blood gas results between 2005 and 2008 while a patient in the UCSF hospital intensive care unit.

Well, that’s it for today’s Breathin Basics lesson. If there’s a particular respiratory topic that you’d like me to write about in a future post, just let me know.

Today’s Breathing Basics review is all about Oxygen Saturation and Oximeters.

If you have lung disease of any kind, no doubt you’ve come across the words “Oxygen saturation” or “O2 Sats” , “Pulse-Oximeter”?
I use those terms on my blog all the time, but do you really know what they mean ? I suppose you could Google a definition, but I think I can probably do a better job of explaining it in a way that makes more sense to the average person, and hopefully in a way that won’t bore you to death.

O2 Saturation is simply a numerical representation ( expressed as a percentage) of how much oxygen is a numerical representation of how much oxygen your blood is carrying at any given moment. This is a useful number to know when someone with a respiratory disorder is ill, because it indicates how well the lungs are functioning and/or how much oxygen is available to the vital organs of the body.

Before I get into how we measure oxygen saturation, let me explain what the term “oxygen saturation” actually means. If you remember some basic human biology, then you already know that we have these little donut shaped cells in our blood called “Red” blood cells or RBC’s for short. Inside these red blood cells is an iron-rich protein called “Hemoglobin” also known as Hb. Well, when hemoglobin comes in contact with oxygen ( in your lungs) it soaks it up like a sponge. It’s actually the combination of oxygen and hemogloblin that gives blood it’s bright red color. The more “saturated” the hemoglobin is, the brighter red the blood becomes. When the Oxygen saturation of the hemoglobin is low, ( usually below 75%), the blood actually gets darker…almost black in color(such as the blood that’s carried in your veins). Each hemoglobin molecule has a certain capacity for oxygen in which it can bind with, and it’s this capacity for oxygen that we are actually measuring when we do a oxygen saturation check… ie. O2 sat. So, if I check my O2 sat and the reading is 95%, this tells me that my hemoglobin is saturated to 95% of it’s carrying capacity. So naturally the more oxygen that gets into the blood stream, the higher the saturation should be.

There are several factors that effect how much oxygen our hemoglobin can hold (O2-oxyhemoglobin disassociation curve), but that’s beyond the scope of this discussion… at least for now. The important thing to understand, is what oxygen saturation is, and how it relates to your particular type of lung ailment. For asthmatics, knowing your O2 sat is probably less important than someone with CF or pulmonary fibrosis or emphysema. That’s because asthma is not a disease that normally effects our ability to oxygenate. Unless you have an extremely chronic and severe form of the disease, you can suffer a pretty nasty asthma attack and still have normal or near O2 sats.

Now that we know what O2 saturation is, how do we measure it? Well, that’s where the handy pulse-oximeter comes in. Hard to believe that this device has only been around for a couple of decades. When I first started working as an RT back in the 1970′s we didn’t have such a luxury. Back then, to measure someones O2 saturation, we had to actually take a blood sample from an artery.. i.e. an ABG ( arterial blood gas), then run it through a special machine that would measure the amount of oxygen dissolved in the plasma, and then hand calculate the results with a slide rule. Talk about a long and drawn out process… not to mention painful.

A pulse ox works is this, when you place the probe on your finger, the top of of it contains a transmitter that shines a beam of light through finger. That beam is absorbed by the hemoglobin in the blood cells as they pass through the the tiny blood vessels in your finger. The receiver at the bottom of the probe, measures the difference in of the returning wavelengths and calculates the O2 Saturation ,which is then displayed on the meter. Because the oximeter needs to be able to differentiate the light absorbed by arterial blood from other interferences, it looks for your pulse. Arterial blood is pumped by the heart, so it pulses and fades with each heartbeat. The oximeter subtracts the trough from peak levels, and the difference is the light absorbed only by the arterial blood. This is why it’s important that you verify that the pulse reading on the oximeter is correct. If your skin to too cold or your blood pressure to low, then it becomes very difficult for the oximeter sense the pulse Pretty cool.

PCO2( carbon dioxide in your blood) is actually more of a concern than O2 saturation when you have an obstructive disease like asthma. We’ll talk about PCO2 the next time around.

This is the 2nd installment of my “ Breathing, the mini series“. This one is more for the non-asthmatics out there, but I think some of our lung challenged friends might learn a thing or two as well.

If you hang around asthmatics or browse as many personal asthma blogs as much as I do, then you’ve undoubtedly stumbled across phrases or symbols like “Green Zone” “ Yellow Zone ” ” Red Zone”… Pfs and the like. To the lay person, these terms might just sound like a flowery way for an asthmatic to describe how they’re breathing at a particular time. In many cases however, these terms are not only used as subjective representations of how an asthmatic might characterize their breathing, but they also represent actual physical measurements from a device used to measure lung function.

Most of is ( if we are wise) use a simple, but accurate tool called a peak flow meter to measure our basic lung function. Peak flow meters work by measuring how fast one can exhale a single full breath. The test result is usually displayed in (lpm) liters per minute and is surprisingly accurate if done correctly. The resulting value, usually a number between 300-600, gives us an accurate reflection of how constricted or obstructed our lungs might be at that moment. The lower the number is, the more obstructed your lungs are and the more difficult it is to breath. The higher the number, the less obstructed and the easier it is to breath.

Because lungs come in difference sizes, shapes and genders, peak flow numbers and ranges will be slightly different for each person. What might be a normal peak flow value for one person, might be an abnormal value for someone else. Normal predicted values are based on age, height , weight and sex, but all this is not important. What is important, is that you determine what your peak flow number is when you’re feeling at your best. This is called your personal best or baseline peak flow . This is the number by which all other peak flow comparisons are made.

Your personal best pf is determined by taking a measurement when you’re breathing at your very best, preferably averaged over several weeks and with no symptoms and /or after taking an inhaler or nebulizer treatment.

The next thing we do is mark our peak flow zones: Peak flow zones are based on your personal best peak flow number. The zones will help you monitor your asthma and take the right actions to keep it under control. The colors used with each zone come from the traffic light ( which btw yours truly made popular).

The result will look something like this:

Here are my personal peak flow zones: (Over the years my personal best pf has dropped from 550 to 350)

Green Zone 300 or greater

Yellow Zone 299-210

Red Zone 209 or less

So why do you need a medical device to tell you if you’re short of breath? Well, believe it or not, there are some asthmatics out there ( myself included), who are not always aware of subtle changes in their breathing. We’re known as poor- perceives or under-perceivers. For us, using a peak flow meter on a regular, and sometimes frequent basis, is crucial for getting a better handle on what’s actually going on with our lungs.

On the opposite end of the spectrum you have what they call over-perceivers. These are folks who are extremely sensitive to even minute changes in breathing pattern. These people should use their peak flow meter to verify whether what they’re feeling is actually being reflected in their peak flow readings. They’re are times when you can feel like and elephant is sitting on your chest, only to find that your peak flow readings are completely normal or just a little off. That’s because our brain and lungs are sometimes not on the same page.

Most asthmatics fall somewhere in the middle , and for them peak flows are usually done on an as needed basis or when they have symptoms.

Well, there you have it. The next time you hear an asthmatic talk about their breathing zones, hopefully you’ll have a better idea of just what the heck they’re talking about….yellow, green , red.. and all those weird zony things.

If you’d like to learn more about the asthma zones, in particular the yellow zone, check out this post I wrote a few years back.

How many times have you had a really bad asthma flare, but had serious trepidations about going to the emergency room for treatment? How many times have you felt guilty that maybe you weren’t sick enough to be admitted to the hospital?

Well, that’s pretty much been the case for me for as long as I can remember. This, despite the fact that Ive become critically ill on more than one occasion, because I waited too long to come in for treatment.

Why do so many chronic asthmatics suffer from low self esteem or feelings of guilt? Why do we often deem ourselves unworthy of emergency care when we truly need it? Why do most of us procrastinate going in for treatment, when we know that the earlier we get in, the better the chances are of reversing a flare up before it gets out of control? Why do so many of us feel guilty or even ashamed and embarrassed about having asthma?

You don’t see people with cancer or other serious medical conditions delaying treatment because they don’t think they’re sick enough. So what makes us so different?
I think it was Dr Wenzel who told me, that this strange behavior is actually quite typical among asthmatics.

Where does all this psychological crap that we pile on ourselves come from? For me it seems to have started in early childhood.

I grew up at a time in the 1960′s and 70′s where ignorance about this disease was rampant. Asthma was considered more of a nuisance illness than a serious medical condition. There was this notion that asthma was a result of weak genes that one would inherit and that there was nothing you could do about it. There was virtually no patient education or preventative care available at the time, and what little was known about the disease turned out to be mostly incorrect. My doctor at the time smoked cigarettes!

There was one incident in particular, that I think really messed with my head. It was an asthma exacerbation I had when I was 14 year old. A mild asthma attack, that almost took my life!
Here’s a little bit of what I remember….

I had been feeling short of breath for several days and none of my medications were working. My Mom had decided that I should probably go to the Emergency room for treatment. We didn’t own a car, or for that matter a working telephone, so the only way I could get there was to take the bus. My Mom wrote a letter for me to give to the doctors giving them permission to treat me, and then sent me on my way.

When I arrived at the hospital I was still able to walk, but I could barely breath. I remember going up to the ER desk and handing the Nurse the note my Mom had written. The intern on duty, a young dude ( we’ll call him Dr. Meany #1) walks up to me and asks “What’s the problem here?” I tell him that I’m having a really bad asthma attack. He rolls his eyes, starts laughing and says…. “That’s like telling me you’re having a heart attack!” “You don’t look like you’re having an asthma attack!” He then listens to my lungs with his stethoscope and says… “I don’t hear any wheezing– you can’t be that bad”. He then orders the nurse to put me in one of the rooms and to give me some kind of injection. The next thing I remember, is waking up in the intensive care unit with a tube shoved down my throat and hooked up to respirator. Less than 30 minutes after being laughed at by the ER doctor I had gone into full blown respiratory arrest while inside the hospital’s elevator on my way to have a chest xray done. (Due to the statue of limitations on the retrieval of medical records, I was unable to ascertain whether I had suffered a cardiac arrest as well.)

A couple of days went by and I was eventually extubated and moved to a regular room. The nightmare however, did not end there. I remember complaining to the nurses that the medicines they were giving me, were making my heart pound and making me nauseated. The next thing I know, another doctor, whom I had never seen before, enters my room and starts yelling at me. He actually starts blaming me for being sick “This is what happens when you don’t take care of your asthma! ” “Why did you wait so long to come in for treatment–You could have died!”
I remember I started to cry while he was scolding me. (Have you ever tried to cry when you can’t breath?)

That’s about all I really remember about that hospitalization, but I know now that it had a profound effect on how I would deal with my asthma in the years that followed. After that incident I would always delay going to the hospital when I got sick, for fear of being ridiculed, laughed at or not taken seriously. I found myself continually raising the ER bar if you will, to higher and higher levels. I would only go to the ER for treatment, if I “looked” sick enough. Even today, 40 years after the fact, I still catch myself trying to hold off from going to the ER until I’m on deaths door, because I don’t want to burden people. How crazy is that!

As for those mean doctors, I can only guess that Dr.Meany#1, had never witnessed a stoic asthmatic child in the middle of a severe flare. The reason I wasn’t wheezing, was because I wasn’t moving ANY air. Hopefully he learned from his near tragic mistake, that not all severe asthmatics act the same when they’re in respiratory failure.
Dr.Meany #2, was probably just annoyed from being called in from home during the middle of the night to treat a patient who had no medical insurance. Or, maybe he was just a jerk. Who knows… All I know is that his comments made me feel like I was a worthless piece of s**t and that my asthma was placing a burden on others.

It’s taken me nearly a half a century and a lengthy career in Respiratory Therapy to finally realize that it’s NOT MY FAULT that I have this disease. Bad things happen to Good people all the time. I think in my case, I was just born at the wrong time in history. I can only imagine how awful it must have been for some asthmatics who were born prior to the 1950′s…. It’s amazing anyone survived!

Thankfully, times have changed for the better now and asthma is receiving a lot more attention. Hospitals and Emergency rooms are much better equipped and the staff much better trained to deal with asthmatic patients. The ER I go to now (UCSF) is excellent. All patients with asthma symptoms are triaged the minute they come though the front door and are given priority based on severity.

My advise to those asthmatics who tend to procrastinate in seeking medical care, for whatever reason, is to figure out why you have these irrational feelings and work on fixing them. If you don’t already have one, get together with your health care provider and devise an asthma action plan that spells out exactly when you should come to the hospital for treatment. If you find yourself not feeling right, but not quite sure if you should go the the ER, just go in. With asthma it’s always better to err on the side caution, even if it means a brief prison stay.

[JP-Facebook-Like]

At first I thought they sent it to me for putting in 25 years of devoted service to the profession, but it turns out that they sent these pins out to every licensed RCP ( Respiratory Care Practitioner) to commemorate 25 years of Respiratory Care as a state regulated profession here in California.

OK.. so maybe I’m not as special as I thought, but if you’re looking for a rewarding career in the medical field, you should consider becoming an RCP. Respiratory therapy has been very good to me over the years, and I can definitely recommend it as a career choice. Check out this brochure

It’s a good field to go into, especially if you’re into helping people who have breathing problems. There’s lots of variety and some great job benefits as well.

And take a look at the average salaries for RTs here in California….
Not bad for a 2 to 4 year education….eh?

Following up on a previous post, I’m happy to announce that the state RCP board has accepted my RCP renewal application. I now have a valid license to practice Respiratory Care in the State of California. Yah….I’m legal again!

I have no plans on ever returning to the traditional work force as an RT, but there’s definitely a sense of security and satisfaction, knowing that I could if I wanted to.

I’m also considering sitting for the National Asthma Educator Certification exam later this year or next. I already do quite a bit of asthma educating from the sidelines, and having official recognition of that skill would be nice to have.

Just as with the RCP license, becoming a “certified” asthma educator is something I don’t really need to do, rather, it’s something that I want to do.

All this buzz about inhalers ,nebulizers and hospitals , got me to thinking of various situations, in which Ive been involved.

Not always practicing what I preach.
As I’m sure Rick would agree, It’s a not always easy being a Respiratory Therapist/Asthmatic. Many times, what you’ve learned as a health professional is at odds with how you deal with your own disease. I cant tell you how many times Ive gone to the ER to instruct a patient on the “correct” way to use their inhaler and spacer, only to turn around a few minutes later and take a few puffs off my own inhaler with complete disregard for technique… or even a spacer for that matter!

RT/Patient
Imagine, you have a really bad asthma flare-up, you’re admitted to the hospital, and first words you hear out of peoples mouths is….” So I heard you’re an RT! ” or ” So , is this why you decided to become an RT?”
I don’t know why, but when I’m the patient, I prefer that the medical staff taking care of me not know that I’m an RT. It just seems to make things more awkward. I think mainly because you can sometimes sense that the people taking care of you, are a little uneasy or let’s say.. not too thrilled about the idea of taking care of an RT/patient.

On the plus side though, I’m sure it keeps the staff on their toes. You can pretty much bet that everything is going to be done by the book. For example: With every single breathing treatment, you’re also going to get; pre & post breath sounds (listening to your lungs with a stethoscope before and after breathing treatments) pre & post oximetry (checking you oxygen saturations) , pre & post PFs, (checking your PFs before and after your treatments)… etc etc. Many times Ill try to put the RT’s at ease by telling them… its OK ..You don’t have to hover over me..my breath sounds haven’t changed in the last hour. Just give me the neb. Go ahead and do another patient while I do my own neb ( a big no-no by the way).

But you know what the most awkward moment usually is? It’s when they need to do an ABG ( arterial blood gas) on you. Even if they don’t show it, you can tell they’re sweating bullets hoping like crazy to hit that artery on the first poke.Nothing more frustrating for an RT, than missing a bounding pulse ( been there–done that).
Come to think of it, the only time I’m treated like a “regular” patient is when I’m intubated (you can’t really talk back). They’re going to suction you no matter what. And when it’s time for you to breath on you’re own ( cpap trial or t-piece) ..they’re ruthless.
Of course when you’ve been admitted to the hospital as many times as I have, its almost impossible for people not to know……its all over my medical records.

MDI Protocol
The last time I was hospitalized, they put me on a continuous Albuterol neb at 20mg/hr. (In case you don’t know, that’s the equivalent of 8 Albuterol treatments PER HOUR! .) And to make the medication work even better, they nebulized it with Heliox . As is pretty typical, they kept me on the continuous neb for about 96 hours. That’s’ around 736 Albuterol treatments in just a 4 day period ! Though my potassium always drops big time, amazingly, my heart rate never gets that high, maybe to about 120-130…(but that’s another blog post).

The point is, when they finally transferred me out of ICU over to the step-down unit, the hospital’s respiratory care protocol kicked in and I was switched from a continuous neb ( which was now at 10mg/hr ), to an Albuterol inhaler of 2-4 puffs Q6 prn. That’s a pretty drastic cut. Needless to say, it didn’t work and a couple hours later I re-flared almost ended up back in the unit.
They ended up putting me back on nebulized treatments , this time Q2 ( every 2 hrs) as needed , which I remained on until discharge. Which brings me to another point. One of things RT’s hate the most (though they may not admit it), is having to give neb treatments to a patient every 2 hours…especially at night. Knowing this, I try to tough it out for as long as I could so dont have to bother them as often.

In the good old days, if they trusted you, and you were physically able, they would leave extra meds at your bedside and let you do your own neb treatments.

Actually, I was going to save this topic for another day when I could spend a lot of time writing it but, for some reason I feel the urge to crank out a few words now.
While I was walking in Golden Gate park today , I was thinking back on my 25+ years as a Respiratory Care Practitioner ( RT for short). If I could do it all over again , would I? If I had to return to work tomorrow , could I?……… I don’t think so..Its pretty stressful work.

The medical field was never my first choice as a career, it was always my second. Medicine would be the path I would take ONLY if things didn’t work out with my real passion… Sound Engineering . At the ripe age of 23 , I was doing what I really loved but , I needed to make money. I needed a stable income and for the first time in my life I realized that I needed my own HEALTH INSURANCE . So healthcare , here I came..

(To be continued)