Jun 29 2012
As I have mentioned in the past, almost all of my practice is inpatient medicine, doing infectious disease consults in acute care hospitals. I only spend three hours a week in the outpatient clinic, so I have a skewed perception of medicine and disease. The patients I see are sick, really sick, often trying to die and are a complicated collection of abnormal labs and deranged physiology.
I remember finishing residency thinking that a potassium of 2.8, a hemoglobin of 9.8 or a bilirubin of 4.5 wasn’t all that bad, losing track of normal physiology amongst all the medical pathology. I never did lose track of normal vital signs (VS): pulse, respiration, blood pressure and temperature. Like trying to be the fifth Beatle, over the years other values have vied to become the fifth vital sign: pain level or O2 saturation, but none have the importance of the fab four. I can live without pain*, but I can’t live long if the other vital signs are abnormal for extended periods of time. Watching the vital signs return to normal is often an important variable that signifies the patient is improving.
“Fever is a mighty engine which Nature brings into the world for conquest of her enemies.” –Thomas Sydenham 1666.
Of course I have an inordinate interest in fevers: their cause, their patterns and their treatment. Fevers lead to consults and while I say my job is ‘me find bug, me kill bug, me go home’, more often it is ‘me find cause of fever, me treat cause fever, fever goes away, me go home’.
One aspect of fever I harp on year after year and where I am continually ignored is the importance of not treating a fever. It is estimated that the fever response is 400 million years old. How do they know that? Got me. Most molecular techniques are “sufficiently advanced technology indistinguishable” from magic; all I know is that they were not measuring core body in T. rex. Every creature that can make a fever will make a fever when infected. All branches of the immune system function better at 102 than 98.2 (yes, 98.2), but in the calorie poor environment most creatures live in, if we maintained our core temp at 102 we would all starve to death. It is also quite remarkable how many potential pathogens cannot grow at 98.2, much less 102. Being above ambient temperature protects against thousands of molds and bacteria.
Almost every animal and human study demonstrates that outcomes are worse if you treat a fever: increase in mortality and/or complications, although it is not always clear if it is the anti-inflammatory or anti-pyretic effects of medications being used that lead to the poorer outcomes. You cannot find studies to demonstrate benefit in treating infections from suppressing fevers.
There are times when you may want to treat a fever: the patient does not have the physiologic reserve from cardiac or pulmonary disease to tolerate the metabolic stress, or they have had a stroke or heart attack or the fevers are high enough to cause damage. In the hospital there are multiple factors that should be considered before whipping out the acetaminophen for an increased fever.
Fevers are an important, evolved response to infection and you inhibit fevers at your patients peril. If a patient had a pulse of 120 or a respiratory rate of 25, you wouldn’t slow them to normal would you? No. You would treat the underlying cause of the tachycardia or tachypnea and watch the vital signs normalize as evidence that your clinical intervention is effective. The same should be true of fevers, although I know all too well that most people expect their fevers to be treated and that no one will believe you if you suggest their fevers should be allowed to run free.
I am listening to The Stand at the moment and most of the world has died off from a biologically engineered superflu. However, everyone who gets a fever seems to take aspirin, so maybe is was the aspirin that helped killed everyone off. It would not be the first time aspirin may have contributed to influenza deaths.
In our household my children do not get antipyretics when they are febrile and I am the one at home taking care of them, and as a result they are calm and quiet. Then I go to work and my wife, a nurse, takes over and treats the fever. Peu d’hommes ont esté admirés par leurs domestiques. Not that my wife is my domestic, but you get the idea. My home is a microcosm of the hospital, n’est pas?
If you have a fever either let it go untreated and you will probably get better faster than if you treated the fever or find and reverse the underlying cause. The same concepts apply to the other vital signs, pulse and respiratory rate, as long as the patient can cope with the physiologic demands of the tachypnea or tachycardia.
The autonomic nervous system is quite a wonder and will compensate though a remarkable range of derangements to keep the vital signs stable at a level to prevent death, although it has its limits. I have seen some remarkable derangements in physiology over the years, some I would have thought incompatible with life, and would have been fatal without ICU intervention. Most of the time for mild to moderate illness the self-regulating systems perform remarkably well keeping the body running along, compensating for whatever pathophysiology is afflicting us and we do not have to think about it.
Breathing is an excellent example. It is a good thing breathing is on autopilot, except for those with Ondines curse or very end stage lung disease, and we do not need to think about our breathing. Helping with acid/base balance and gas exchange (out goes the bad air, CO2, in goes the good, O2) we breathe until we breathe our last.
Many illnesses will alter how we breathe, both the rate and pattern, and you can get a hint as to the underlying disease if you know some pathophysiology and watch a patient breathe. It is fun to walk in a room and see Kussmaul breathing or Cheyne-Stokes respiration and think oooohhhhh, I know what might be going on. Being under almost total automatic control, there is not much most people can do about their breathing for any significant period of time. You can neither breath fast nor hold your breath without soon giving in to the metabolic demands for equilibrium.
Let’s see, can you guess what I am going to write about?
1) Discovered by lone genius? Check.
2) The one true cause of all disease? Check.
3) One treatment for all disease? Check.
4) Divorced from physiology? Check.
5) Lots of positive testimonials, minimal clinical trials for efficacy. Check.
6) “Ironically, his work was never fully accepted by his colleagues” Check.
7) Lack of understanding of the word ironic. Check.
Chiropractic? Reiki? Therapeutic Touch? Homeopathy? So many lone geniuses who discover the cause and treatment of disease to the benefit of mankind yet unproven and ignored by the closed minded medical industrial complex. Or is this SCAM paradolia on my part? Not quite Robert Parks Seven Warning Signs of Bogus Science, but in its spirit.
Somehow I got on the mailing list for one of the most impressive bass ackwards alt therapies I have yet to find. The Breathing Center in Woodstock New York keeps sending me emails, suggesting, amongst other things, that I spend my vacation breathing away my medical problems with the official Representation of the Clinica Buteyki Moscow, home of the Buteyko breathing technique.
Lets go through the list.
1) Lone Genius
Konstantin Buteyko was a Russian physician who was evidently dying of severe hypertension, oddly painful, and more likely panic attacks in the early 1950’s. One night he was contemplating his mortality during what sounds like a panic attack when he noted he was breathing deeply and rapidly though his mouth. He slowed his breathing down and immediately felt better. He tried it on an asthma patient who was having an asthma attack and, by slowing the breathing rate down, the asthma attack subsided.
Eureka. Chronic hyperventilation was not the effect of disease but the cause of disease. Like I said. Bass ackwards. Based on this N of 2, he then began treating patients with all manner of diseases with, it is maintained, great effect.
2) The one true cause of disease.
There is a list of over 150 diseases reported to be caused by chronic hyperventilation, including cancer and AIDS. Chronic hypoventilation is also the cause of a disease reported, at least that I can find, only on the Buteyko sites, perplexed sclerosis. Must be a spelling error, but I can’t think of for what.
As best I can tell, all diseases are in part caused by chronic hyperventilation, which is present in at least 90% of people. The chronic hyperventilation leads to chronic hypocapnia (low CO2) which results in a multitude of adverse metabolic effects and diseases. In medicine, low CO2 from overbreathing results in a respiratory alkalosis. This begs for an Epic Rap Battle: Buteyko with respiratory alkalosis as the cause of all disease against Robert O. Young with acidosis as the cause of all disease. They can’t both be right can they? But they can both be wrong.
Here is where I am old school. Alterations in breathing are the result, not the cause of disease, and there is almost no reason to suspect otherwise.
3) The one true treatment of disease
Breathing slowly and shallowly through your nose will reverses the chronic hyperventilation, reverses all the detrimental metabolic effects, and cures or improves all disease. I doubt it. Based on simple prior probability nose breathing would be as likely to have an effect on post-operative scars, hypothyroidism, gingivitis or pyelonephritis, to pick 4 off the list of 150, as homeopathy or reiki. It would, I think, would be excellent in the treatment of perplexed sclerosis, a disease that has defied all other interventions, conventional or alternative.
Here, however, is room for pause, I would not say categorically, it doesn’t work and can’t work. Most of the clinical evaluations of Buteyko have been not for perplexed sclerosis and other diseases, but asthma.
However, if you have ever seen someone with a bad asthma attack and the panic that ensues with difficulty breathing, worsening the attack, you would not be surprised if patients do better when given control over their asthma/breathing. Part of treating patients with acute severe shortness of breath is getting them to calm down and relax. Suffocating is not fun and panic adds to that feeling.
There may also be benefit from raising CO2 in patients with asthma, although the effect is probably not clinically relevant.
There is in vitro animal evidence suggesting that low alveolar PCO2 causes bronchoconstriction, while a high PCO2 acts directly on the airway smooth muscle to cause bronchodilatation. There is also in vivo animal evidence that hypocapnia increases airway resistance. In addition, there is support for the association between hypocapnia and bronchoconstriction from experimental evidence from humans.
I also note for a time my pulmonologists were fans of permissive hypercapnia on hard to ventilate patients and I confess to not paying much attention: the various modes of vital sign support come and go in the ICU (they still have not figured out optimal pressor use as best I can tell) depending of the current state of the art, and not being an active part of my practice, I defer to others as the benefits and risks. Me find bug, you know?
Reading the literature on the Pubmeds would suggest an improvement in subjective symptoms, a decrease in medication use, but no physiologic alterations:
No significant change in FEV1 (forced expiratory volume in one second) was recorded in either group. The BBT group exhibited a reduction in inhaled steroid use of 50% and beta2-agonist use of 85% at six months from baseline. In the control group inhaled steroid use was unchanged and beta2-agonist use was reduced by 37% from baseline
and little support for the proposed mechanism of increasing the CO2 as the cause of improvement.
It is placebo effect: the patient believing there is improvement where none is occurring, and as usual I have mixed feelings. Giving people control over their disease will make them feel better, especially when the disease has a strong emotional component, as the feeling of the inability to breathe will always engender. Doing so under what appears to be false premises, not so much. I get the impression that people are more willing to live with whatever their pulmonary function is and, because of the control, less likely to use medications inappropriately or prn.
I suspect it is not the specific intervention, but shifting to a sense of control over your disease that is important:
Where meta-analyses could be done, they provided evidence of benefit from yoga, Buteyko breathing technique and physiotherapist-led breathing training in improving asthma-related quality of life.
4) Divorced from known anatomy and physiology.
For the most part. As mentioned, with the exception of reactive airway disease, there is no reason to suspect that the mighty 150 diseases Byteyko thought were amenable to his therapy is caused in anyway from chronic hyperventilation. It is the best example of mistaking cause and effect I have ever witnessed. Of course, I am old school. Respiration is for gas exchange and little else. No known physiology would lead to suspecting that mild, chronic hypocapnia, even if it were present, would lead to any disease. Sorry. Except for perplexed sclerosis. I have become enamored of perplexed sclerosis, which does not even have an ICD-10 code although it is on many of the Buteyko sites. So I can neither confirm nor deny its Buteyko-ian physiology.
5) Lots of positive testimonials, minimal clinical trials for efficacy
As mentioned a review of the Pubmeds finds little meat on the bones of the assertion that the 150 are amenable to treatment by slow nose breathing. There are numerous testimonials on the interwebs, reaffirming the credo that the plural of anecdote is anecdotes, not data. Most concern asthma, few other diseases are mentioned except in passing. Some testifiers had a diminution in kidney stones and eczema. No testimonial that I can find mentioned improvement in their perplexed sclerosis, which deeply saddened me.
6) “Ironically, his work was never fully accepted by his colleagues.”
Buteyko been ignored by the medical industrial complex and for good reason: he is wrong on basic principals and there is a lack of proven efficacy for most of the mighty 150.
7) The American Heritage Dictionary defines irony as: “incongruity between what might be expected and what actually occurs.” Since Buteyko is wrong, there is no irony in his never being accepted by his colleagues, who, I am sure, prefer reality to fantasy in treating most diseases, except, of course, the dread perplexed sclerosis.
At least no one tries to alter the blood pressure or pulse as an alternative treatment, although there is the imaginary taking of the pulse as part of pseudo-diagnosis in TCM. Half the vital signs are safe from SCAM interventions. I hope.
So the take home today: don’t treat a fever. Avoid perplexed sclerosis. And breathe normally my friends.
*Well, I can’t. Those born without the ability to feel pain usually die young and do not grow up to terrorize Lisbeth Salander.
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