Do people hate asthmatics?

Sometimes I wonder if the good folks over at the FDA and EPA hate asthmatics.  They forced many good asthma medicines off the market with the Montreal Protocol, and they scared doctors into no longer prescribing other medicines that work great for some asthmatics when used as prescribed.

Personally I never cared for Intal, although I know of many asthmatics who got along great with the medicine.  Too bad!  It's been taken off the market  Theophylline is no longer a top line asthma medicine, but at least it's still on the market.  But that doesn't matter, doctors are so scared to use it (even though it was safely used for many years).

The FDA has put so many warnings on Advair that my doctor has been trying to convince me to use Symbicort for five years now.  The problem is that Advair works just fine, and I've used it safely since 2003.  It's the first medicine to really allow me to control my asthma. 

The problem with Symbicort is it makes me feel as though I have an electric volt running through my body.  Symbicort works great, even better than Advair, yet I'm not willing to put up with that side effect.  It's a great option (something the Fed doesn't like I presume) for asthmatics, although not a good option for me.  

The Montreal Protocol has caused a spike in asthma medicines that has made them too expensive for most asthmatics.  I can honestly tell you that about 80 percent of the asthmatics I see daily in the emergency room are asthmatics who can't afford their asthma prescriptions they already have.

I have no problem with the Montreal Protocol.  I have no problem with making an effort to protect nature.  Yet I do have a problem when those making decisions put nature over people.  

As you can see from my list here, I place people over nature.  It seems the Fed has priorities reversed.  

To be honest, I think HFA inhalers work better than CFC inhalers.  Science has proven it's equally effective and even gets deeper into the lungs for better distribution of the medicine.  It's even better than DPIs, which is why Advair recently came out with an inhaler  

Yet I see no reason why options can't be left on the table for asthmatics, options that would also keep prices down so asthmatics can get the control that is possible if they are on these medicines.  As it is, it appears many folks love their planet before the God fearing people who live on it.  

So, my question is:  Do people hate asthmatics?  

1194-800 B.C. Medicine in Ancient Greece

If you had an internal disease like asthma around 1194-800 B.C., chances are you wouldn't go to see a doctor. Physicians existed, but they were more trained to treat wounds such as those obtained in battle.   The person you'd go to see would be your priest, magician or witch.

The reason was simple:  most ancient societies, the Greeks included, believed disease was caused by the wrath of the gods.  To get your remedy you needed to find a person -- a priest, witch or magician -- to help you find out which god was mad at you and why.  Then you'd have to learn how to make that god happy again so you would have a shot at getting better, explains Henry E. Sigerist in his book, "A History of Medicine."  (1)

Yet the more common option, as Sigerist notes, was be to seek out your priest to learn what kind of offerings to make to the gods for healing in this way.  This was more common because it was far less expensive than seeking a potion offered by a magician or witch.  (1)

He may prescribe fore you a magic amulet, an incantation, and quite possibly an animal sacrifice, a pig perhaps, or a goat. Such a sacrifice would show the angry god that you value his wisdom over your own possessions. Since the gods were thought to live and breathe like men in the Heavens, the sacrifice was thought to provide a food offering to the god.

This was a common form of medicine in the ancient world, a bribe of sorts.  I will provide you with this food offering if you make me well again.

A common ritual was to travel to the god's temple by walking, riding a horse, riding a donkey, or riding a cart.  The temple belongs to one of the healing gods, such as Ascepius.  You'd spend time amid the priests, who had the ability to talk to the gods and hear their advice for healing.  Most often you'd sleep among them, and in the morning your cure would be revealed.

In this way, you received the healing benefits this god had to offer.

There were many such temples scattered around ancient Greece, and often they were associated with nearby hostels to house those who traveled for this purpose. Some early historians, Sigerist said, believed these "hostels attached to the Ascelpia were the first Western hospitals and poorhouses where indigent sick people stay and are treated by priest," writes Sigerist (1, page 73)

Later historians note that these weren't hospitals in the way we think of them today, as the sick merely spent time there to learn the cure; they did not stay in the hostels until they were healed, but just one night.

Priestly healing was very common during this era.  In fact, the belief gods were responsible for good luck and bad luck, health and healing, made worshiping the god Ascepius very popular even up to the Birth of Jesus Christ.  Sigerist explaines that it was for this reason the pagan god Ascepius was the greatest competitor of Jesus Christ. (1)

Sigerist said that one of the main reasons Ascepius was the greatest competitor to Jesus Christ was because he wasn't as greedy as the other gods, and he would accept even modest gifts.  This made it possible for him to be worshiped by both the rich and the poor. (1)

This was significant, because poverty was one of the main attractions of Christianity.  The poor couldn't afford physicians, nor the sacrifices demanded of most gods, and so Christianity was a viable option.  Yet so too was the god Asclepius.

Over time there was another medical paradigm that was growing in popularity and significance in ancient Greece, and that was the belief in natural medicine.  Some priest physicians were knowledgeable of which plants had medicinal and poisonous properties.  As time progressed, even the common folks were privy to this knowledge.

A good example of this was explained in the Odyssey by the great Greek poet Homer.  Henry E. Sigerist, explains the following: (1)

"There is relatively little mention of magic in the Homeric epics although the ancient Greeks believed in magic and, like everyone else in antiquity, practiced some...  The drug given to Helen by the Egyptian lady, Polydamna, had strong euphoric properties, so that whoever took it forgot all unpleasant memories and would not shed a tear even if his closest relative died; this drug might be opium or hashish, but it could just as well be the kind of miracle drug found in many fairy tales." (1)

As Sigerist explained, the Odyssey cannot be taken seriously, however, it was based on real life events. The Greeks probably had access to various medicines, such as opium, and simply told of this medicine as a magic potion crated by, say, witches or magicians.  Since the gods created everything, then they must have also created the magical powers present in some plants.

Knowledge of the inner organs and what they did was limited, yet observations from experience working with the wounded and the dead gave soldiers a pretty good idea where to aim their weapons to produce the most damage to the enemy's body.  They knew the best places to aim were the lower abdomen or to aim their arrows at the nipples.

Physicians had magic healing powders and soothing drugs used to help people who were wounded in battle.  These tales also describe various poisons.  For example, Sigerist noted a line from Homer's Odyssey:

"Circe was a beautiful witch who could transform human beings into pigs, and it is absurd to assume that Eurylochus who told the story had been the victim of hallucinations."  (1)

While these stories are twisted and turned into a memorable fairy tales, they may actually be descriptions of poisons used to punish or kill an enemy.   What these drugs and medicines actually were we can only speculate.

While all ancient medicine started off as mythical, natural medicine was soon a viable option. Natural medicine may have been resisted at first, although through time its benefits were so obvious they couldn't be resisted.  So, of course, natural remedies found their way to mythology.

Note: The dates chosen for this article are based on the estimated dates for the writings of Homer (800 B.C.) and the siege of Troy as described in Homer's Iliad (1194-1184 B.C.). The medical knowledge expressed in this post may also have effected you prior to and after these listed dates, which are mainly listed simply as a reference to make it easier to write a history, and easier to picture in your head where these events may have occurred. And even if you lived in Greece during these times, you may also have been subjected to primitive medicine, or pre-Greek medicine. I obtained the dates from Albert Henry Buck in his book "The growth of medicine from the earliest times to about 1800." (1917, London, Oxford University Press, page 46).

References:

1. Sigerist, Henry E, "A History of Medicine," vol. II, "Early Greek, Hindu, and Persian Medicine," 1961, Oxford University Press, pages 19, 20, 23, 28, 51

Why the hang up on theophylline?

Perhaps I'm a stubborn old asthmatic (although I'm only 42), or perhaps I have a viable argument, but I contend it's time physicians got over their fear of theophylline and start prescribing it again for asthmatics who need it.  

Between 1972 and 2007 I was chronically addicted to the substance.  That sounds bad in and of itself, but the theophylline worked.  It worked to keep my lungs opened up.  It helped me and thousands of other asthmatics before Long Acting Beta Adrenergics were combined with improved inhaled corticosteroids.  

Before I started taking Advair in 2003, and when I forgot a dose of theophylline (which was most often Theo-dur), my airways twitched and an asthmatic attack often ensued.  These attacks were the worse ever, and a sure sign of my addiction.  Getting off the substance was something I yearned, yet never hoped for.  

After starting Advair I observed I didn't have such attacks when I missed a dose of theophylline.  It was at this point I started talking to my doctor about weaning myself off the theophylline.  It took a year, and I succeeded.

Now fast forward five years.  Thanks to allergies the Advair is sometimes not enough to prevent an asthma attack.  When I had one last year at hunting camp, I suffered all night and the entire weekend before my breath came all the way back.  

The next time that happened, and I felt panicked, I reached into my medicine cabinet and grabbed the bottle of theophylline I kept in their as a momento of my long-time addiction to the product.  I downed one.  Thirty minutes later my breath came back.  

A month later the same happened, and the theophylline pulled me from the grips of an asthma attack once again.  So I talked to my doctor about this hoping he'd at least give me one bottle of theophylline so I didn't have to dip into the five year old bottle.  He said no.  

Why?  If something works so well, why not let me have it.  It makes me kind of almost upset I told him I was able to wean myself off it.  

To his defense, he gave me a prednisone pack.  That's great, but why would I take prednisone for two weeks when one theophyllline would pull me out of an attack?  It is my view that one theophylline pill would be much safer than two weeks of prednisone.   He disagreed.

I suppose I should add the fear of theophylline to my growing list of myths of respiratory therapy.  It's not like you can get high off theophylline, and it's not like I want to take it regularly.  I tolerated it without side effects for more than 30 years.  So why the hang up?  

I don't want to waste valuable time at a doctor/patient visit to discuss this.  However, one of these days I'm going to run into him on a slow day at work, and I'm going to embellish him with compliments and suck him into a discussion about theophylline.

Related post:

• Theophylline no longer a top line asthma medicine

800 B.C: Homer was first to use the term asthma

Bust of Homer (British Museum, London). By using the term
asthma in his epic poem The Illiad, he became the first to
use the term in written literature.  

As a child Homer (800 or 850 B.C.) listened to poems recited by his dad about a war that occurred almost 400 years before he was born.  He was so impressed that as a young man he many spent hours in the open courtyard writing them down.

He couldn't remember word per word the stories his dad told.  What made it even more confusing was that his uncle sang the same stories, only the twists and turns were different. The names used, the plot, the ending, and the morals learned, however, were the same no matter who told the story.

So as he was jotting down the stories from memory, he realized it was okay to exaggerate and to expound at times in order to make his story more complete.  The important thing was to have the story in writing so future fathers could tell the same story every time it was told.  

As the years passed Homer became so rapt in his task that he became the slightly obese middle-aged, bearded man that is represented in the various busts of him. He would go down in history as one of the first and greatest story tellers of all time.

Whether or not he was actually the first to tell these stories may never be known, although what is known is he is often given credit.  This was because, unlike the ancient Egyptians and Mediterraneans, the ancient Greeks liked to associate works of writing to either the author or some famous person.  While Homer may not have been the creator of the Iliad, since he wrote it down he is given credit by history as the author.  (1, page 19-20)

It was a story of a siege at Troy estimated to have occurred between 1194-1184 B.C. (4, page 46)  After writing this story, Homer would write many more.  As eluded to above, he probably obtained most of his stories from those told by his ancestors by word of mouth, mainly through poems and songs that were easy to remember.  (1, pages 19-20)

Another thing Homer did, as his father and uncle did earlier, was add into the story modern events.  This made the story more interesting to the modern audience. While he may not have known it at the time, this would give future historians a better idea of what life was like in ancient Greece.  (1, page 19-20)

The story would also become significant to medical historians, because Homer made allusions to the state of medicine at the time.  While he described the battles, he also described battle wounds, and the symptoms that resulted from these wounds, sometimes in the process of dying.  So various medical historians have made reference to these allusions as some of the earliest knowledge of medicine. (1, page 19-20)

Homer was also the first, or so it is thought, to use the term asthma (άσθμα) in an actual piece of literature. (2, pages 10-11)

The term asthma is referenced in the Iliad, book XV, line 10:

"He saw Hector lying on the plain, his companions
sitting round him. Hector was gagging painfully,
dazed and vomiting blood." 

In this scene Zeus wakes up as the Greeks are trying to push a line of Trojans back, and he finds the Trojan leader Hector breathing painfully and vomiting blood. The above is the English translation, although the word Homer used for "gagging painfully" was asthma or asthmati.

Homer later made another reference to asthma in the Iliad, book XV, line 290:

"He was just starting to recover,
to recognize his comrades round him. He'd stopped
gasping and sweating, for aegis-bearing Zeushad revived his mind"

In this scene Homer described Hector as just starting to catch his breath.

Homer used the term asthma to refer to being winded as from fighting in battle, or as from wounds obtained in battle.  It made sense to use the term asthma this way, because it was a term meaning short, gasping breaths.  It was a vague term used simply to describe the symptom of dyspnea, or shortness of breath, regardless of t cause.

Another term that was sometimes used by the Greeks was panos, which meant panting.  Homer apparently preferred the term asthma.

Another early description of asthma was the sacred disease.  Actually, epilepsy was the sacred disease because the seizures were thought to be caused by divine intervention.  Those with the disease were thought to be rewarded with happiness in the next world.

Asthma was also referred to as the sacred disease simply because it was thought to be epilepsy of the lungs.  Perhaps the gasping efforts of the asthmatic made the chest appear as though it were seizing.  So if you had asthma you were blessed with eternal happiness.

While asthma was considered a divine blessing, this does not mean that the gods didn't cause all other diseases too, because they did.  This is confirmed, perhaps, by homer in his Odyssey (ix. 411):

 "the blinded and howling Cyclops is told by his friend that, if he is ill, he should remember that sickness comes from Zeus and is unavoidable." (3, page 38)  

Homer did not, however, refer to the disease asthma. His use of the term was simply to describe the symptom of dyspnea.

References:

1. Sigerist, Henry E, "A History of Medicine," Volume II, 1961, Oxford University Press, New York, pages 19-20
2. Jackson, Mark, "Asthma: The Biography," 2009, Oxford University Press, pages 10-11.  Note:  While Mark Jackson is not the only person to acknowledge the Iliad as the first reference to the term asthma, I still want to give him credit here.  
3. Withington, Edward, "Medical History from the earliest times," 1894, London, page 38
4. Buck, Albert Henry, Williams Memorial Public Funds, "The growth of medicine from the earliest times to about 1800," 1917, London, Oxford University Press

1970-present: History of Incentive Spirometer

Why are incentive Spirometers used?

During the 1950s physicians had access to effective anesthetics and methods of breathing for patients while they were under, such as bag mask ventilator (Ambu-Bags) and eventually positive pressure ventilators.  It was during this time that surgeries became common place in hospitals.  Yet it didn't take long for physicians to realize that even while the operation may be successful, about 20 percent of these patients developed post operative respiratory complications that confounded caring for these patients.  (2)

The most common surgery during this time was abdominal surgeries.  By 1957 it was well documented that about 20 percent of patients getting abdominal surgeries (particularly upper abdominal surgeries) were retaining secretions and developing pneumonia.  It was ultimately determined this was happening because these patients weren't taking deep enough breaths.  (2)

Studies showed that during normal breathing, shallow breaths may result in collapse of some alveoli, yet at a certain point the person will naturally take in a deep breath that supplies "sufficient pressure to reopen the collapsed alveoli."  A study performed in 1964 showed that these deep breaths, generally referred to as a sigh or yawn, occur normally about five to ten times every hour.  (2)

Furthermore, studies showed this normal pattern of breathing was abolished by general anesthesia and by narcotics like morphine that were needed to keep these patients comfortable.  Shallow breathing that results from both pain from thoracic or upper abdominal surgeries, anesthesia and pain relievers causes a prolonged abnormal breathing pattern (shallow and without sighs).

Due to this shallow breathing these patients were unable to clear secretions, and this resulted in retained secretions.  The end result of shallow breathing and retained secretions were alveolar regions that weren't being ventilated (hypoventilation) adequately, and this was resulting in atelectasis.  To further complicate things, retained secretions create a breeding ground for bacteria, and pneumonia may result.

Other studies in the 1960s confirmed that patients with Chronic Bronchitis, Emphysema, or patients who are heavy smokers, and people who are overweight, tend to have reduced lung volumes to begin with are are at the greatest risk for developing post operative complications.  This group, it was learned, had to be treated especially careful.

Generally it was learned that only a small portion of patients with atelectasis develop pneumonia, but the challenge became knowing which patients were at greatest risk.  Yet pneumonia further complicates caring for a patients, and sometimes ends in death.  In fact, studies done in the 1970s showed that respiratory failure was the cause or a contributing factor in about 50 percent of postoperative deaths.  (6)

The question left to the experts was what to do to prevent and treat post operative complications.

The first treatment for post operative atelectasis is?

Since it was difficult to know for sure which patients would develop post operative complications, it became obvious that all such patients had to be treated prophetically in the hopes of preventing any problems.  If atelectasis or pneumonia developed anyway, those conditions were treated accordingly with oxygen, antibiotics, or mechanical ventilation if needed.  Yet the ultimate goal was to prevent the need for those treatments.

One of the simplest solutions suggested was get these patient moving as soon as possible, although with some surgeries this may not be possible. Certainly cough and deep breathing (C&DB) exercises would be encouraged, but many patients had no incentive to do this when the nurse or doctor wasn't around. It was likewise learned by studies that most post operative patients didn't take a deep enough breath to be therapeutic.  (1)

When the first Intermittent Positive Pressure Breathing machines were introduced to the market in the mid 1950s these were thought to force enough air into a patients lungs to prevent post operative complications.  It was common for patients to get 10-15 minute IPPB treatments with Isuprel.

Yet studies in the 1970s showed this therapy to be ineffective because most patients were not allowing the machines to fill their lungs with air.  Other studies showed the tidal volume achieved through such therapy was still not enough to be therapeutic.

Through the next two decades such IPPB therapy was phased out.  I wrote about the IPPB Revolution in respiratory therapy in this post.

Another option that became available was blow bottles, where the patient was encouraged to exhale forcefully to prevent these symptoms. It was basically a glorified method to help the patient clear secretions.  According to Dennis Glover in his book, "The History of Respiratory Therapy" the "patient exhales into a bottle partially filled with water, which creates resistance to his or her effort."  (4)

Yet this therapy was soon learned to be ineffective because, as Glover explained, it further collapsed the airways, which was the opposite effect as desired.  Blow bottle therapy was also proven to be more painful for the patient than inhaling, considering most muscles of respiration are for expiration.  Therefore it was determine the best way to prevent and treat atelectasis was inhaling, not exhaling.  (1)

So the market was open for some sort of device here.  This inspired many medical experts, and entrepreneurs pent on profiting from this new need, into getting creative. It provided a new use for an old device that was actually first used way back in 1840 to prevent consumption as I wrote here.

So this brings us to the Incentive Spirometer

The idea of taking a deep breath to prevent post and treat post operative patients was first mentioned in medical literature in 1915 by  MacMahon.  He worked with soldiers who were injured in battle, and recognized many were developing post operative respiratory complications.  He recommended chest physiotherapy, exercise and taking deep breaths.  (9)

In this way, MacMahon may have been the first to describe forced expiration to prevent and treat post operative respiratory complications.  He wrote:  "the patient breathes in through the nose and the lower ribs are felt to be strongly expanding. The mouth is opened wide and the abdominal muscles slowly and strongly contracted, so that the air is driven from the lungs." (9)

By the 1960s there was ample evidence that taking in a deep breath and holding it for 3-5 seconds was an effective means of preventing atelectasis.  This technique worked similar to a sigh or yawn.  In 1966 a study was performed that showed taking a deep breath without a breath hold was not effective in preventing atelectasis, so emphasis must be made on the slow, deep breath with breath hold.  This method -- the sigh --was also proven to treat atelectasis by returning the lungs to normal.  (2)

Yet studies already suggested that patients didn't do a good enough job of this on their own, without coaching, or without some sort of a device.  It was for this reason that some sort of device was needed.  (2)  In 1966 a report was written recommending deep breathing exercises every hour. (7) And another report in 1980 even played on this suggesting perhaps the reason IPPB didn't work as effectively as incentive spirometry is because IPPB therapy is only done every four hours.  (6)  Thankfully that researcher didn't get his way, or RTs would have been even more inundated with IPPB therapies that were ultimately proven to be an embarrassment to the RT profession.

Spirocare Incentive Spirometer (1975)

The incentive spirometer was invented in 1970 by R.H. Bartlett and written about in his article "Physiology of Yawning & Its Application to Post Operative Care which appeared in Surgical Forum in 1970.  The device was neat because it was a device that sat on the bedside table and acted as a reminder -- an incentive if you will -- for them to remember to take breaths.

The device encouraged the patient to take in a deep breath, with a breath hold, that was "reproducible"  and simulated the required yawn.  It also gave positive feedback because the patient could see actual results, and goals could be set. (2)

The first incentive spirometer (IS) wasn't like the disposable plastic units we use today.  It was an electric device that lit up when the desired volume was reached.

Like the modern devices, the patient would put his mouth on a mouthpiece, and inhale.  A bellow inside the device would rise on inspiration, which could be measured if between 200 and 2000 ml.  After treatment the patient encouraged to cough, and expectorate secretions if possible.

Playing on this concept, Marion Laboratories trademarked the Spirocare electric incentive spirometer in 1975, according to trademarkia.com.  It was called the Sprirocare Electronic Incentive Breathing Excersisor.  The trademark actually didn't expire until 1997, although the devices ceased being used long before that in favor of the modern, plastic disposable, less expensive units.

The following is from an advertisement in the January 1974 issue of Chest (Volume 65/ number 1, January 1974, page A-15):

"Meet Spirocare, the new incentive breathing exercisor.  A self-contained, portable instrument, designed to assist the postoperative or chronic pulmonary patient.

Operation is extremely simple:  You select an air volume goal for your patient.  The patient then inhales through a disposable impellaway flowmeter.  As the volume of inhaled air increases, the patient can see the illuminated numbers light up until the preselected goal is reached.  A visual counter records the number of times the goal is achieved. 

The device is interesting to watch, so patient motivation is easily maintained.  Cross contamination is eliminated through use of the disposable impellaway flowmeter.

The Spirocare unit offers precise flow-rate measurements from 200cc/sec to 10,000 cc/sec.  An internal optical scanning system provides digital output and illuminated signals based on the computer-counted rotation of the impeller.  It is easily the most sophisticated instrument of its type. 

Today's there are many brands of incentive spirometers, and they are plastic, made for individual use, and disposable. The concept is the same, however.  Most such devices have some sort of object, like a ball or balls or bellow, that the patient has to keep above a line.  After taking about ten such breaths with a breath hold the patient is encouraged to cough.  (1) Once again, the goal here is to mimic a sigh, which was proven to prevent hypoventilation, atelectasis, and further postoperative complications.

So, are incentive spirometers better than other methods?

A modern incentive spirometer

Various studies done in the 1970s ultimately (or supposedly) provided enough evidence that blow bottle therapy and IPPB therapy were ineffective in treating post operative atelectasis, at least when compared with the insentive spirometer.  One such study in 1978 compared the three methods and showed that all three improved atelectasis to some degree, with the incentive spirometer being the most effective with the least side effects. (5)

A study reported that IPPB therapy, done ineffectively, often resulted in air in the stomach and this resulted in about 9 percent of patients having distended stomachs, and 20% having stomach complications. There was also a high incidence of post operative nausea in patients receiveing IPPB therapy (16%), as compared with insentive spirometery and blow bottle therapy (2%).

Ultimately, the incentive spirometer was recomended by the researchers as it resulted in 15% of post operative patients using it developing post operative complications compared with 30% of patients using IPPB therapy developing complications. However, blow bottle therapy resulted in an incidence of only 8% experiencing post operative complications.  (5)

A modern incentive spirometer

The greatest advantage was that incentive spirometer and blow bottle therapy costs about half as much as IPPB therapy.  As per 1978 dollars, the cost of setting up all three treatments was $9.00, but the cost of subsequent IPPB treatments was $7.50 compared with $3.00 for IS and blow bottle therapy.  (5)

The ultimate results of this study were that IS and blowby therapy were both superior to IPPB therapy.  It didn't take long, however, of both IPPB and blow bottle therapy to both be phased out in favor of IS therapy.  However, while blow bottle therapy was quickly phased out, IPPB therapy was slower to be phased out.  Some doctors continue to prescribe it for some comlicated post operative cases and are convinced it does some good.

Stunningly, nn 2001 a group of researchers collected the entire database of studies regarding the incentive spirometer, and they concluded that "the evidence does not support the use of IS for decreasing the incidence of PPCs (postoperative pulmonary complications) following cardiac or upper abdominal surgery.  (10)  Other researchers and authors concur that "there is little evidence to support the use of IS in airway clearance, but it is still used today. (9)

So there really are no conclusive studies showing the incentive spirometer is any better at preventing post operative complications than blow bottles or IPPB therapy.  Although in the end the IS was chosen as the preferred method mainly due to ease of use and cost. 

Conclusion

Regardless of lack of evidence that the IS is effective in preventing and treating postoperative pulmonary complications, most medical professionals recommend its use. Most hospitals have protocols that call for a respiratory therapist to give one to all post operative patients, and properly instruct them on its use.

Usually the patient is instructed to take 10 good breaths through the device once every hour while awake.  Most patients can do this on their own, while others require further encouragement or assistance.

Likewise, despite lack of evidence supporting it's effectiveness, many quality assurance programs insist on an IS being ordered for the patient to meet reimbursement criteria.  So needless to say, IS therapy is still commonly prescribed. In fact, it's quite common to see a respiratory therapist trudging into patient rooms with an incentive spirometer in hand.

References:

1. Bartlett, R. H. et al., "Physiology of Yawning & Its Application to Post Operative Care," Surgical Forum, 1970, pp. 222-224. . "Doctors Test Yawn Box," Boston Evening Globe, Oct. 14, 1970.. 
2. Craven, J, et al, "The Evaluation of the Incentive Spirometer in the Management of Posoperative Pulmonary Complications," British Journal of Surgery, 1974, vol 61, pages 793-97
3. George, Ronald B, et all, "Chest Medicine: Essentials of Pulmonary and Critical Care Medicine," 2005, Philadelphia, page 567 
4. Glover, Dennis, "The history of Respiratory Therapy: Discovery and Evolution," 2010, Indiana, page 79
5. Leigh, I.G., et al, "A comparative study of IPPB, the Incentive Spirometer, and Blow Bottles; The Prevention of Atelectasis Following Cardiac Surgery," Ann Thorac Surg, 1978; 25; 197-200
6. Kigen, Colleen M, "Chest Physical Therapy for the Postoperative or Traumatic Injury Patient," Physical Therapy, 1981; 61; pages 1724-1736
7. Ward, R.H., et al, "An evaluation of post operative respiratory meneuvers," Surg Gynecol Obstet, 1966, 123; pages 51-54
8. MacMahon, C, "Breathing and physical exercises for use caes of wounds in the pleura, lung and diaphragm," Lancet, 1915, pages 769-70
9. Pryor, JA, "Physiotherapy for airway clearance in adults," European Respiratory Journal, 1999, 14, pages 1418-24
10. Overland, Tom J., et al, "The Effect of Incentive Spirometry on Postoperative Pulmonary Complications: A Systemic Review," Chest, September 2001, vol. 120, no. 3, pa

The pocket size spacer?

Every study I've ever seen on the subject show that using an inhaler with a spacer makes the medicine work up to 75 percent better than not using an inhaler.  Respiratory therapists, myself included, are taught never to give an inhaler to a patient without a spacer. 

This Optihaler is marketed as a "pocket spacer." Sure it's smaller than most spacers, but I can't imagine stuffing... no! Can you? It just wouldn't be good.

Manufacturers and marketers are gonna have to keep working on this one.  In the meantime, I find my rescue inhaler works just fine without a spacer. 

3000 B.C. to present: History of chest physiotherapy

Scientists have recently discovered evidence of emphysema, chronic bronchitis, pneumonia and other diseases that cause thick secretions in mummified human remains.  So it's evident humans have had to deal with these conditions from the beginning of human existence.

Ancient Assyrian texts that may date back 3,000 years show evidence that doctors way back then made efforts to help these patients.  One Assyrian text describes the following:

"If the patient suffers from hissing cough, if his wind-pipe is full of murmurs, if he coughs, if he has coughing fits, if he has phlegm: bray together roses and mustard in purified oil, drop it on his tongue, fill, moreover, a tube with it and blow it into his nostrils. Thereafter he shall drink several times beer of the finest quality; thus he will recover." (1, 2)

There were various herbal and medicinal options available to doctors in various regions of the world, although due to lack of communication between civilizations, and the lack of any organized medical groups, methods of airway clearance didn't become uniform in the medical community until recent times.

Chest physiotherapy (CPT) is one of the simplest methods of helping a patient clear thick secretions.  The technique involves cupping your hands and clapping on the patient's back and chest. This is often accompanied with postural drainage, which involves having the patient lie or sit  in different positions in order to promote the drainage of secretions from different areas of the chest.

The use of postural drainage was first mentioned by S. H. Quincke in 1898.  He recommended "intermittent" use of postural drainage to treat patients with thick secretions.  Yet this technique wasn't adapted by the medical community until William Ewart recommended CPT with postural drainage in 1901.  (2)

Ewart worked with children with bronchiectasis, and he recommended "continuous postural drainage" as opposed to "intermittent" to these children in order to promote the removal of thick tenacious secretions.  By continuous he meant that it should be done frequently, as opposed to just once a day.   Generally, the treatment was prescribed 3-4 times a day for up to 10 minutes, and this is still how it's ordered today for the same reasons.(3)

While Ewart may have spearheaded the idea of CPT and postural drainage for bronchiectasis and eventually cystic fibrosis patients, the use of these techniques was ultimately found to be useful to prevent and treat complications that result from performing surgeries.  Physicians noted many of their post operative patients were developing respiratory complications not related to the surgery itself, and they sought to understand and find a solution.

This concept of using CPT to prevent and treat post operative respiratory complications was first described in 1915 by MacMahon in an article about how to treat post operative trauma patients.  In fact, not only did he recommend the use of CPT, he also recognized the importance of exercising as soon as possible after a surgery to get the lungs back to normal, or their pre-operative status.  (4)

Most of the patients MacMahon treated were soldiers injured in battle.  He recommended CPT with exercise, and forced exhalation, and reported that the results were "remarkable," particularly within one week.  By 1919 there was an increasing body of evidence to suggest that where there is "serious lung collapse and chest deformity following wounds or illness, breathing and physical exercises should, in certain cases, be given as accessories to medical and surgical treatment, if the best possible recovery is to be assured."  (2)

Yet it wasn't until the 1950s, when surgeries started to be a mainstay in hospitals (due to improved anesthetics), that any extensive studies were performed to determine the efficacy of doing the procedure, according to Colleen M. Kigin in her 1981 article in Physical Therapy "."Chest Physical Therapy for the Postoperative or Traumatic Injury Patient,"  (5)

Kigin explained that Loius Pasteur first recognized atelectasis in 1908 after "temporary inhibition of muscular activity." In the 1930s studies showed a link between post operative respiratory distress and hypoxemia (low oxygen in the blood).  In 1952 atelectasis was recognized by R.N.V. Palmer and BA Sellick as the most common cause of post operative complications.  (5, 6)

Palmer and Sellick described that some of the best results in treating these complications are by using percussion, postural drainage, and treatments with isoprenaline.  They were among the first to recognize the value of using beta adrenergics to treat and prevent post operative complications.  The idea was that anesthesia causes "reflex bronchospasm" and this results in the retention of secretions.  They concluded that Isoprenaline given before and during anesthesia treated this perceived problem by dilating airways and enhancing secretion clearance in that way.  (7)

It was during the 1950s that the medical community decided that intermittent positive pressure breathing was an effective method of preventing and treating post operative respiratory complications.  This technique forced air into the patients lungs, and it was believed that this helped them take a deep enough breath to open collapsed alveoli.  This technique was proven to be ineffective in the 1970s.  I wrote about the IPPB revolution in this post.

Overall, and other than trials of IPPB therapy, the "gold standard" for preventing post operative pulmonary complications was chest physiotherapy until the 1960s when other methods, such as the incentive spirometer, were discovered to also benefit such patients.  There were also some mechanical percusors available, yet there was never any conclusive evidence they did any better of a job than CPT.  Whether to use cupped hands or a mechanical device was generally left to the institution or therapist. (2)

In 1970 the incentive spirometer (IS) was invented.  It was believed to be more effective than any of the other methods used to promote airway clearance because it could be done by the patient alone.  Seeing this device on the bedside table acted as a reminder or an incentive to take deep breaths.  Likewise, being able to see how high they could make the bellow or balls move up acted as positive feedback.  The patient and the physician could also monitor progress. I wrote about the history if the IS here.

During the 1970s many studies were done to determine the effects of both the incentive spirometer and CPT.  A 1974 article in the British Journal of Surgery studied a group of post operative patients that were treated with CPT and another group treated with IS therapy.  The CPT was done only twice a day, and the IS every hour.  Those in the group receiving CPT had a 63 percent chance of developing post operative complications, and those in the IS group had only a 37% chance of developing complications.  The researchers decided CPT may have been less effective because deep breathing exercises weren't encouraged. (8)

Flutter Valve

During the early 1990s the flutter device was introduced to the market as an alternative to CPT to help with mucus clearance.  It's a hand held device that the patient blows into.  This causes ball bearings inside it to "oscillate at a high frequency, aresulting in vibrations of the airways and intermittent positive expiratoto facilitate mucus expectoration."  While studies show CPT is a better method of helping patinets with cystic fibrosis remove secretions and improve lung volumes, other studies showed that use of a flutter device was even more effective.  Studies also showed that CF patients coughed up three times as much with the flutter as compared to CPT. (10)

Since study sample sizes of studies comparing the various devices for airway clearance have been small, it's difficult to get a dininitive answer as to which one is best to use.  However, based on present study results, it does seem that the flutter valve is a useful technique (11)  Still, which technique to use is a personal preference.  Use of a flutter device is nice because the patient can do it on his own, although the initial expense of flutter devices cost significantly more than CPT.

Acapella (PEP devices)

Another device introduced about the same time as the Flutter valve to help with airway clearance was a Positive Expiratory Pressure (PEP) device called the Acapella. These devices create both oscillations and PEP similar to the flutter valve, although the mechanisms are different.  (12) Some studies show PEP therapy may be even more effective than flutter valves in helping patinets remove secretions, although, once again, sample sizes are small, so obtaining a difinitive answer is difficult.  (13)

Other studies are even more inconclusive, and state there is no evidence one method is any better than the other.  (14)

While CPT, PEP and flutter valves are ordered in hospitals based on availability and personal preference, most hospitals continue to have regular protocols for giving incentive spirometers to most post operative patients.  While there has never been a study that has proven the incentive spirometer has any effect on treating and preventing post operative respiratory complications, (9) most hospitals have developed protocols that recommend all post operative patients be given an incentive spirometer by a respiratory therapist, be educated on how to use it, and encouraged to use it at least 10 times every hour.

Many hospital protocols go a step further and instruct patients how to use these devices prior to surgeries, especially those who will get upper abdominal and thoracic surgeries.  I think this is a good idea because it can be difficult to teach this device to patients when they are sedated after surgery.  It's also nice to know how well they did on it before surgery so we know when their lung volumes are back to normal.

Some physicians throw the gamete at all post operative patients. We have one doctor who orders post operative patients to get an albuterol breathing treatment, incentive spirometer, and CPT four times every day for three day.  Some doctors only order one or more of these procedures when a patient develops a fever, which is a common sign of atelectasis.  However, it must be known that there has never been a conclusive study showing any of these methods do any good.

Yet regardless of all the technology, CPT continues to be the gold standard method of helping patients promote airway clearance.  Regardless of what studies say, just havintg a respiratory therapist in the room moving the patient from side to side assures the physician the patient will be assessed and moved on a regular basis.  This alone may all that most patients need for a speedy recovery.

References:  

1. Sigerist HE, "A History of Medicine. Vol 1. Primitive and Archaic Medicine," 1951, New York, Oxford University Press, 1951; p. 481
2. Pryor, JA, "Physiotherapy for airway clearance in adults," European Respiratory Journal, 1999, 14, pages 1418-24
3. Nelson, HP, "Postural Drainage of the Lungs," The British Medical Journal, August 11, 1934, pages 251-255
4. MacMahon, C, "Breathing and physical exercises for use caes of wounds in the pleura, lung and diaphragm," Lancet, 1915, pages 769-70
5. Kigen, Colleen M, "Chest Physical Therapy for the Postoperative or Traumatic Injury Patient," Physical Therapy, 1981; 61; pages 1724-1736
6. Palmer, RNV, Sellick BA, "The Prevention of Post Operative Pulmonary Atelectasis," Lancet, 1953, 1; pages 164-168
7. Odell, J.R., "Prevention of Post Operative Chest Complicaitons," Anesthesia, January, 1959, Vol 14, no. 1, pages 68-75
8. Craven, J.L., et al, "The evaluation of incentive spirometer in the management of post operative pulmonary complications," British Journal of Surgery, 1974, 61, pages 793-7
9. Overland, Tom J., et al, "The Effect of Incentive Spirometry on Postoperative Pulmonary Complications: A Systemic Review," Chest, September 2001, vol. 120, no. 3, pages 971-978
10. Gondor, Megdalen, et al, "Comparison of Flutter Device and Physical Therapy in the Treatment of Cystic Fibrosis Pulmonary Exacerbation," Pediatric Pulmonology, 1999, 28; pages 255-260
11. Homnick, DN, K. Anderson, JH Marks, "Comparison of the flutter device standard chest physiotherapy in hospitalized patients with cystic fibrosis: a pilot study," Chest, 1998, 114, pages 993-997
12. Volsko, Teressa, et al, "Performance Comparison of Two Oscillating Positive Expiratory Pressure Devices: Acapella versus Flutter," Respiratory Care, 2003, 48 (2), pages 124-130
13. Mcllwaine, P.M., et al, "Long-term comparative trial of positive expiratory pressure versus oscillating positive expiratory pressure (flutter) physiotherapy in the treatment of cystic fibrosis, Journal of Pediatrics, 2001, June, 138 (6), pages 845-50
14. Westerdahl, Orman J, "Chest physiotherapy with positive expiratory pressure breathing after abdominal and thoracic surgery: a systematic review," 2009, Oct. 29, vol. 54, issue 3, pages 261-267