1689-1970: The slow death of a killer called Consumption

By 1880 a few physicians suspected tuberculosis to be contagious, but the idea was not rock solid in the medical community.  In fact, the idea had been brought up many times, perhaps the first time as bar back as the ancient Greeks (1, page 16), and once again in 1020 by Avicenna.

Avicenna discovered the disease could spread through soil and water, and created quarantines to prevent the spread of the disease.  Yet despite this early success, progress as far as the disease tuberculosis was concerned was slow.  The disease continued to scare people until well into the 20th century.

The following are some of the major advancements that helped end the tuberculosis scare:

1. 1689 Dr. Richard Morton determined the pulmonary form was associated with tubercles in the lungs
2. 1696 Giorgio Baglivi observed the tuberculosis patients got better after a sword wound to the chest.  This was the first observation that a pneumothorax (collapsed lung) might benefit the progress of the disease and induce healing.
3. 1834:  F.H. Ramadge performed the first successful surgery where the lungs of a patient with TB were intentionally collapsed.  Ramadge did extensive research on TB, and even invented an inhaling pipe to treat the disease.
4. 1839 J.L. Schonlein, noting the tubercle, identified tuberculosis as a single disease
5. 1854 the first tuberculosis sanatorium was opened in Gorbersdorf, Germany (now in Poland) by Hermann Brehmer.
6. 1882 Robert Koch identified Mycobacterium tuberculosis.  He thought his glycerinie extract of the tubercle bacilli would be a remedy, but it wasn't.  However, it was later adapted as a test for TB.
7. In 1895 William Rontgen discovered the x-ray, and this allowed physicians to detect the disease early and monitor its progression
8. 1906 lbert Calmette and Camille Guérin in 1906 had success immunizing against a strain of tuberculosis.  They invented what they called the BCG vaccination and used it first in France.
9. 1930s Plombage Technique was trialed to remove infected part of lung.  The part of lung was forced to collapse, and was thought to heal quicker.  Some of these patients had their chest stuffed with ping pong balls or similar objects to prevent their chest from caving in.  There actually was success between the 30s and 50s until the antibiotic was proven to be more successful
10. 1944 Streptomycin discovered as an effective treatment for tuberculosis
11. 1952 Isoniazid invented as the first effective oral drug to treat TB
12. 1967 Rifampin was another antibiotic discovered to treat the disease, it was introduced to the market in the 1970s

All of these discoveries and inventions helped with the treatment of the disease, although it was studies of tuberculosis patients at sanatoriums like National Jewish Health in Denver, Colorado, that truly helped prove the disease was spread most by places associated with poor hygiene.  

Initial studies showed a high incidence of TB among sweat shops in New York and Chicago and similar occupations where there were crowds of people in places associated with poor hygiene.  Efforts were made to educate people of important positions, and laws were passed by cities, especially the New York legislature, forcing improved hygienic practices in public work places.

Major campaigns were begun to discourage people from spitting in public places.  Hand washing was encouraged.  People were encouraged wash and bathe often.  People were educated about the disease, and this, perhaps even more so than the TB test and the vaccine that was later invented, lead to the demise of the disease.

Another significant improvement was the sanatoriums that opened up all over the United States and Europe.  These allowed for the patients to get state of the art treatment, yet it also provided an opportunity to educate them that their disease is communicable, and easily spread to others.  They were educated to not spit in handkerchiefs that sat around.  Plus these sanatoriums kept the TB patients isolated from society, and this also helped prevent the spread of the disease.

All of this helped decrease the number of tuberculosis patients, and tuberculosis deaths, yet what was the true triumph was the discovery in 1946 of the antibiotic streptomycin.  Now there was an effective cure, or at least treatment, for the disease.  Yet still, to prevent the spread, a focus must remain on good hygiene.  This effort continues to this day. 

And the breath came back, with a little euphoria

As my readers know, I was back in the ER for asthma after 16 years of avoiding that place (as a patient). For about 24 hours that visit seemed to be doing the trick, when Sunday night came. My asthma got worse, to the point I was sitting up at 2 a.m. on Sunday night taking back to back to back ventolin treatments. I decided I had to go back to the ER. I decided I had to call work in the morning and call in sick for Tuesday. Yes, the decision was made. But....

... it was 2 a.m. My wife had been up with me the night before (because I was telling her I was getting worse), and she traveled all day with the kids to get shoes and clothes for school. She was beat, and sleeping sound. I, your humble RT, did not want to bother her. Hmmm, kind of reminds me when I was a kid and was kind to my parents during just about any of my nocturnal asthma attacks. But...

...'tis how I was made, caring more for others, even in my dyspneic state, than myself. So here I am, trying to sleep, body lifted up slightly by my right arm, under three pillows... yeah, if you've been there, you know what I'm talking about. I'm lying there, rolling over more than once, and am thinking that maybe I should sleep (not sleep) on the couch so I don't wake up my wife. My mind keeps wandering to what I'm going to tell my doctor when I see him for yet another unscheduled visit this year (asthma, blood pressure, sore feet, old age...). Yes, too bad my xanax has been used up. But...

... you know, sometimes miracles happen. Yes, it's kind of neat how that preasure barrier works on breathing. Was very sob Sunday about 2 a.m. thinking about going back to the ER -- knowing I HAD to go back to the ER, when somehow, miraculously, I became so exhausted (struggling mightely to get half a breath, that I fell asleep. I even dreamed an asthmatic dream. Then I woke up...

... it was around 3:30 a.m. A cool, refreshing pressure free breeze blew threw the window, and it was like... ahhhhhhhhh, I can breathe. It brings upon one of those post asthmatic attack euphoric moments. It's the most wonderful feeling in the world.

So, now I'm feeling just as bad as I felt the night I went to the ER, only now it feels so good, because it's better than how I was at 2 a.m. this Sunday morning. I certainly don't feel normal, although I did go to work today, Tuesday. I figured I'd take the easy assignment...

yeah, right! ER was swamped for my coworker, and I had four ventilators. However, when you work with great coworkers as I do, it's easy to work with asthma, taking the occasional breathing treatment in the RT supply room. Thankfully, however, those treatments were now only required every four hours (although I certainly was ready for them as they were inhaled). So, 'tis the life of your humble RT asthmatic. Later.

1932: The first use of the term 'Aerosol' x

Many asthmatics participate in what is sometimes referred to as Aerosol Therapy.  When you take a breathing treatment you are basically aerosolizing medicine so it can be inhaled.  While aerosols are present through history, the term wasn't used until the 1930s.

It was first used i 1932 by R. Whitlaw and and E. Gray Patterson.  The term is derived in the following manner (1, page 173):

• Aer = air
• sol = solution

In subsequent years various generic terms have also been used, which include the following (1, page 173, (2 page 5):

• Mist
• Micromist
• Fog
• Fume
• Spray
• Haze
• Smog

The term aerosol basically refers to "the suspension of a liquid or solid particle in a gaseous medium. The term originated as the gas phase analogue to hydrosols (meaning 'water particle' in Greek) and refers to suspension of particles in a liquid." (2, page 3)  Most "theories describing aerosol behavior assume the particles are spherical." (2, page 6)

Aerosolized particles generally average in size from barely larger than a molecule to as large as 100 micrograms.  Although for the purpose of aerosolized particles to reach the respiratory tract, the following is necessary (3):

1. Greater than 10 um deposits in the nose
2. Greater than 5 um deposits in the mouth
3. 5-10 um deposits in the first six generations of bronchi (large airways)
4. 1-5 um deposits in the last 5-6 generations 
5. 0.8-2 um are optimal for alveolar deposition

Particles smaller than 10 micrograms generally hold their contents well, so the medicine is not likely to be lost upon aeroslization.  (2, page 9)  It's for this reason respiratory medicine can be mixed together in the same solution.

References:

1. Korting, Monika Schafer, editor, "Drug Delivery," 2010, Germany, Springer-Verlag Berlin Heidelberg.  The reference used for this information is Aiche, 1990)  Although a more specific reference would be Whitlaw-Gray, R, and Patterson, H.S., in "Smoke: A Study of Aerial Disperse Systems," (Arnold, London, 1932), 192 pages
2. Kulkarni, Pramod, Paul A. Baron, Klaus Willeke, editors, "Aerosol Measurement: Principles, Techniques and Applications," 3rd edition, 2011, Wiley
3. Elliot, Deborah, Patrick Dunne, "A Guide to Aerosolized Drug Delivery," American Association of Respiratory Care, page 9.  I wrote about this at RT Cave as you can see here. 

Asthma update: 2 days after first ER visit in 16 years

So my wife woke up around 2 p.m., her late arousal due to her working 3rd shift last night, and she pokes her head into the garage where I'm sitting in a chair, watching both the Tigers on TV and my little tykes bounce in the bounce house, and play in the kiddie pool. 

She says, "So, how's your asthma?"

Me says, with a smile, "The same."

"Are you still taking Q1 hour treatments?"

"Yep." 

"So you're the asthma expert.  If you were giving yourself advice, what advice would you give?"

"Go back to the ER."

"So are you gonna?"

"Nope."

"Nope, hey?"

" I don't want to have to explain how my asthma isn't normal again, only to get lectured about how I shouldn't use my ventolin so often.  No thanks. Besides, I'm already on steroids, so what else can they do for me.  I'll just wait until Tuesday when (my Internist) will be in his office, and hope I can get in."

"So what are you gonna do?"

"Well, as you can see, I still cleaned the house and the garage."

"Yeah, looks nice."

"Thanks."

"Chez," she says, and closes the door.  

So that's my asthma update.  

The best part of my ER visit...

... was my respiratory therapist.  I knew Jenny was busy.  I saw her on my way back to fast track giving a treatment to a kid.  Turns out the kid was really sic.  Turns out she also had a trauma she had to get off in the ambulance.  Yet even as she explained this to me, noting that she was swamped, she did so with a smile, and she sat with me while she gave the treatment.  Her beeper went off several times during the treatment, and each time she grimace and groaned, although she did so with a smile.  As she left the room she jokingly offered me a sucker.  Perhaps this is a bias on my part, but I think my RT gave me better customer service, and with a smile, than any of the other people who took care of me that day.  Even though she was obviously busy, and rushed, she was cheerful and did a great job caring for me.  

My first trip to the ER in 16 years

For sixteen and a half years I've managed to stay out of the emergency room as an asthma patient.  That was the longest streak of my 43 years on this planet.  The previous long was 4 years, from 1993 to 1997.  Yet, as they always say, good streaks always come to an end.

So I was sitting around, or, rather, pacing back and forth, worrying about what I should do. I was also using my ventolin with increased frequency over the past week and a half.  I actually wrote a post about this once: "Having asthma symptoms? Here's five tips to help you decide what to do." Based on my own tips, I decided it was time to take the plunge and go to the emergency room.  

It was awkward being the patient, as in the triage room I sat on the wrong side of the desk, generating a laugh from the triage nurse.  Twice as a different person came to introduce herself, saying something like, "Hi, I'm Sarah from admitting," I almost said, "Hi, I'm Rick from Respiratory Therapy."  I also have this habit of thanking people. "Thanks for giving me that shot." 

It was my pleasure," the nurse said.  

I added, "What really makes me happy is you gave it in the side of my hip as opposed to my butt, so now I can still sit."

She laughed, "That's what I like about you, Rick." 

The worse part about the visit was that they sent me to a portion of our ER called Fast Track, where a nurse practitioner was pretending to be doctor.  I had tough time explaining to her that I did not have ordinary asthma.  Finally, as she was lecturing me about how I use my ventolin so much, my wife chimed in on my behalf.  She said:

"Rick has had severe persistent asthma his entire life.  He had trouble with it as a kid, and even spent six months at a research hospital once.  He takes all the best asthma medicines, and still needs to take his rescue medicine every four hours, and sometimes more, on a good day: that's as good as it will ever get for him.  If he came to the ER every time he used his inhaler every hour, he'd be in here every day."

That cheered me right up. That flustered the NP, who had trouble speaking after that, and yearned to get out of the room.  But before she could escape, she had to defend her position, although she sputtered in the process.

She came back a while later, and she said she was debating giving me an antibiotic.  I said, "I don't think I need any, as I have no symptoms other than asthma.  But I'll do whatever you want."  I actually wanted to say, "why don't you just do some lab tests, and an xray, to make sure I'm okay."  I think further testing would give me further peace of mind, perhaps relieving some of my anxiety (yes, 300 puffs of ventolin and steroids does increase anxiety).

In good jest, she offered me a sucker.  I said, "How about some xanax?"  She said she couldn't give xanax, but she could give Ativan.  Later, a nurse came in with 1 mg of ativan in a syringe.  

"At home he takes .5 mg of xanax, and 1 mg of ativan is like 2 mg of xanax.  How about giving him half of that so he can function at home," my brilliant wife said (yes, she is also a nurse). "It doesn't make sense that she would give that much ativan when one .5mg xanax works for him just fine."

My thought was: "Dough! Wifey, what are you doing."  But the .5mg ativan worked great, as I got my best night sleep last night in the past week.  I do not, however, feel much better this morning, so we'll have to see how this turns out.  If I end up going back to that place, I'm going to insist on seeing a doctor in the ER, someone who knows a little about asthma; or at least someone with a little common sense. 

I am an asthma conundrum

What is frustrating about my asthma is that I feel worse than I look.  Seriously!  I feel like I can't get a full, deep breath in, and I can feel that I have air trapping when I exhale, but I don't look short of breath at all.  The only way the people around me know I'm short of breath is because I tell them, and I think that deep down my wife probably wonders if I'm making it all up.  But she loves me and so she trusts that I'm telling the truth. 

That's the delimma I have with my asthma.  I was actually having a really good summer asthma wise, until about a week and a half ago when I was rummaging through boxes in my basement.  Since then I've felt this way.  I currently have no allergy symptoms and no signs of a cold.  It feels, to me, like pure asthma.   I've used up a ton of ventolin, via both the inhaler and nebulizer route.  I've gone through at least 2 full inhalers, and who knows how many Albuterol nebulizer treatments. 

The treatments help open me up and make me feel better, although in the end I still don't feel perfectly opened up.  Still, my regular routine of life has not bee effected.  Although, considering I've been pumping so much ventolin into my system, I've been extremely anxious lately, as might be expected.  This is probably exacerbated by the fact I've been getting up several times in the night to puff on my inhaler.  Or, worse, to take continuous breathing treatments in the morning hoping to catch my breath so I can get back to sleep.  But usually, after taking this action, I'm so wired I can't sleep.

So I'm working tonight, and I'm walking around doing my work, when I feel tight.  Well, I've been mildly short of breath all night and all day yesterday, but at the moment I was feeling worse.  So I went back to the department to give myself a breathing treatment, when I decided to run myself through the whole gammut of tests. 

I did a pre and post peak flow: 

• pre: 750 (maxed device out)
• Post:  750:  (maxed device out)

Then I did a pulmonary function test on myself:

• Pre Duoneb breathing treatment
• FVC: 4.42 or 85% predicted
• FEV1: 3.64 or 88% predicted
• FEV1/FVC: 82
• FEF25-75: 3.66 or 96% predicted
• FEF Max: 10.09 or 103% predicted
• Post Duoneb breathing treatment
• FVC: 4.42 or +3
• FEV1: 3.90 or +7
• FEV1/FVC: 86
• FEF 25-75: 4.64 or +27
• FEF Max: 11.20 or +7

Based on these results, you can see that all of these tests show greater than 80% or predicted, which would show that I have normal lung function.  Now from the graphic, you can see a slight obstructed patern, although nothing significant.  However, there is a nice improvement with the Duoneb, so the PFT does shoe a benefit with bronchodilator. 

Still, this is frustrating for me, because I feel like I have air trapping.  I feel like I don't feel normal, so I started myself on a prednisone pack today, yet I really don't fee significantly better after doing that.  What stinks is I was hoping doing this PFT would help me decide what the next course of action is for me to do if these steroids don't kick in soon.  I actually was thinking of going to the ER after work, and I was hoping these tests results would ease my mind a bit.  But not so. 

It could be all in my head, I suppose.  However, as I take a deep breath, and feel that something is in there.  And as I exhale, my exhalation is prolonged and wheezy.  Welp, tis the life of being a hardluck asthmatic.  Yet as you can see here, none of these tests match how I feel. That peak flow meter is about useless to me. 

Now, one more thing I want to add.  You might find this awkward, and I sometimes wonder if any other asthmatics have had the same thing happen.  Once all my kids are up, and things are situated around the house, I go into the basement and do my workout.  Yes, I even run on the treadmill (or wog, or whatever you call it. But at least I do it).

Even yesterday morning, after getting out of bed and telling my wife "I'm still having trouble breathing," I said, "And I'm going into the basement to run on the treadmill."  She said, "How can you run on the treadmill if you can't breath."   I said, "Life must go on." 

My point there was that for some reason my asthma doesn't seem to get worse when I'm running on the treadmill.  Why that is I have no clue.  But I'm going to take advantage of it, because I know from my experience if I let myself get out of shape, I get dyspneic from being overweight, and then everything gets nasty.  So if I can, I work out.  And I have.  But I do a light workout as opposed to a vigourous one when I'm like this.  It goes along with the asthma experts who insist that you should always exercise even when  you have hardluck asthma, or no matter how bad your asthma is. 

So I started a medtol pack after much delay, mainly because it's normal for me to dilly dally, to hymm and haw, and to come up with excuses not to do anything.  Asthma can be so awkward at times.   My asthma is awkward.  It's a conundrum.  It'a a major riddle.  I yearn to see if any of my asthma friends have ever experienced anything like this: where your asthma does not match your appearance, and all your tests are normal, even better than normal (such as your PFTs).  Thoughts?