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Vital Signs

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.

Breathing exercises in general have no utility in asthma, at least for objective findings  and the Buteyko method would appear to be no different.

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.

Notes

*Well, I can’t. Those born without the ability to feel pain usually die young and do not grow up to terrorize Lisbeth Salander.

Posted in: Energy Medicine, Faith Healing & Spirituality, Science and Medicine

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50 thoughts on “Vital Signs

  1. daijiyobu says:

    Portland, Oregon has ND Czeranko
    who promotes Buteyko.

    [no, that is not the beginning of a dirty Limerick, though I'm almost tempted...].

    She is a CCNM grad. and “curator of the rare book collection at National College of Natural Medicine.” At her site, http://www.breathingacademy.com/ , she states:

    “Buteyko breathing is a clinically validated, groundbreaking five day program grounded in the half century of clinical research work of Dr. Konstantine Buteyko.” She speaks of “over-breathing” and “the root of dysfunctional breathing.”

    Sigh [how anecdotal, I'm feeling better already with that sigh].

    But, what’s really interesting right now, is that ND Czeranko has a two-part article in Naturopathic Doctor News & Review [a naturopathic 'journal' at http://ndnr.com/ ] on, of all oddities,

    phrenology!

    And don’t forget, and NDNR reminds us, naturopathy is “based upon the objective observation of the nature of health and disease [...and is] continually reexamined in the light of scientific advances” [http://ndnr.com/naturopathic/ ].

    The second part of the series hasn’t arrived at my door yet. The first part was quite historical and, you guessed it, credulous. Perhaps, the second part will talk of how to get phrenology out of its coffin and employ it in the here and now.

    There’s nothing like reanimated nonsense. Count on naturopathy to truly provide, under the false label of science, zombie sCAMs!

    -r.c.

  2. Emma says:

    I’m not a hundred percent sure but I believe that the term “perplexed sclerosis” may have come about as a translation mistake.

    In Russian, the word for ‘multiple sclerosis’ is ‘рассеяный склероз/rassejannyj skleroz’. The adjective ‘rassejannyj’ means ‘scattered; absent-minded’. However there is also a semantically related but not synonymous adjective, namely, ‘растерянный/rasterjannyj’ which is usually translated with ‘perplexed’. (The two words sound also rather similar.)

    It seems to me that the original translator, translating from Russian into English, confused these two adjectives, rendering mistakenly ‘scattered/disseminated’ with ‘perplexed’.

  3. WilliamLawrenceUtridge says:

    Stieg Larsson reference. Much better than Paolini, I approve.

  4. Janet Camp says:

    As to fever, I had a family practice doc (in Portland) advise me to quit fussing (I really was fussing) about one of my offspring having frequent fevers. He said it was just a sign that his immune system was doing its job and not to bother him unless we were talking 102 or more. Now, I’m pretty sure my altie chums would have thought him an arrogant allopathic ass, but I thought about it and saw that he was right and we lived happily ever after until the kid grew pot in his bedroom and got busted (his own bedroom/apt, not mine). It must have been the fevers!
    ———–
    Re breathing:

    Isn’t it kind of hard to breathe deeply through your nose when you are having an asthma attack induced by severe hay fever? That has been my experience anyway–although I acknowledge that that is only an anecdote.

    @daijiyobu

    I used to use phrenology as the most absurd example of woo that I could come up with; alas, now that is also gone. I also thought the tuning fork one was the weirdest–until a friend who lives in poverty somehow came up with the money to buy a complete set because she was sure it would cure her–ah, um–stupidity?

  5. INTRANEURAL says:

    “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.”

    Dr. Crislip,

    I am curious as to why you state this. Pulse oximetry is an enormously useful vital sign particularly in the ICU and in the OR, where I spend the majority of my time. Another particularly useful vital sign/measurement is capnography. The practice of anesthesia was altered by these two measurements. The most important would be confirming tracheal intubation. Pulse oximetry is useful to indicate hypoxia, hints at hypovolemia with pulse wave variation, and can even be utilized as a monitor of ventilation if a patient is on room air (very rapid desaturations if a patient is apneic or hypo ventilating). The ability to correct O2 sats with PEEP indicates atelectasis and one can help to differentiate between dead space and shunt.

    Capnography, though never vying for the “fifth vital sign” is probably my favorite monitor indicating hypo/hyperventilation, cardiac output and adequacy of resuscitation, rebreathing, obstruction, embolus, etc. Both of these monitors are invaluable in ICU/Anesthesiology. I use them everyday on multiple patients. EKG, pulse, temp, and BP are enormously important as well and I will not deny this. I just do not see how these two monitors/vital signs are any less important. Thanks again for a great post.

  6. DavidRLogan says:

    These issues regarding breath control are interesting (this, QiGong, meditation, etc.) The OP is in many ways persuasive (and fun to read!), but I think a more moderate view’s in order with respect to hypervention and hypocapnia. Hyperventilation’s certainly a result of dysfunction, but couldn’t the door open both ways (HV and dysfunction intensifying eachother)? By “moderate view” I also mean any such exercises should clearly be an adjunct to SBM rather than a first line treatment as Buteyko (who also holds quite an extreme view) suggests.

    It’s a bit much to say “no known physiology” would invite suspicion about the effects of chronic hypocapnia, or there is “no reason” to suspect such pathophys (I agree there’s little/no clinical evidence for this particular intervention…but the OP went beyond *only* that claim). If nobody wants to read my whole post, I sequestered the physiology to below…

    In the spirit of this board I express my skepticism rather than all the things with which I agreed. I hope I generate some disagreement, in the past the criticism from y’all has helped me formulate a better view and not make the same mistakes in other situations (in class, etc.) That’s why I’m posting/reading here even though I’m occasionally self-aggrandizing.

    ————————————————————————————–

    Regarding the physiology of C02 and hypocapnia: at least one of the ways thyroid (T3) stimulates metabolism is facilitating the conversion of pyruvate to Acetyl CoA, increasing C02 from the TCA cycle. If you kill a mouse with too much cytomel (I don’t admit to doing this) you’ll find the mouse is extremely emaciated, but also its bones are much stronger than a *normal* sacrificed mouse. Thyroid promotes the creation of C02, C02 strengthens the bones, probably by binding to lysine residues and forming a carbamino anion which will bind to calcium. By regulating bone calcium in this manner the gas (and sugar metabolism) can effect PTH and calcitonin…if’s that right now we are talking about C02 as part of a huge crosstalk system with some of the big hormonal players. The change in C02 from hyperventilation is not insignificant or “mild”…easy to measure with a metabolic cage or painstakingly with boring calculations from the known products of metabolism…we can store 100′s of liters in our bones.

    Moreover, we find in many diseases extremely high ratios of NADH to NAD+…the mitochondria are *shut down* and the electron carriers are trying to dump their e’s to pyruvate to make lactate. C02 production is lower without the TCA cycle and cytoplasm is overreduced (this is shown for instance with the presence of large #’s of SH groups). C02 itself will resist some of these problems…it’s a strong lewis acid so it can pull electrons out of the system, it’s presence on te RBC’s causes oxygen content to be increased in the tissues, etc… some oldschool physiologists like Koch suggested its role may be in some situations like the quinones, but C02 is a self generating compound of this sort. I could go on and on but FWIW I don’t think C02 reduction in hypoventilation is mild or it is beyond our understanding of physiology to think hyperventilation would effect metabolism as well as be effected.

  7. DavidRLogan says:

    Sorry about the bad spelling…”hyperventilation” in the first paragraph. I typed that way too fast.

  8. DavidRLogan says:

    Oh and I love the little 98.2 tidbit…thanks for that! Wow I’ve overposted :*(

  9. Harriet Hall says:

    I use antipyretics not to treat the level of the temperature but to treat misery. I haven’t seen any clear evidence that outcomes are worse with antipyretics for most of the common conditions we use them for at home, and even if there were a statistically significant difference, I doubt whether it would equate to a clinically significant difference. IMO, in most cases the benefit of relieving the subjective misery outweighs the very small risk of a minimal adverse impact on objective outcomes. If a kid has a high fever but is playing happily, there’s no reason to give him Tylenol. If he is lethargic, whiny, miserable, and obviously suffering, that’s a reason.

  10. daedalus2u says:

    Raising body temperature during infection is practiced by virtually all vertebrates, and also by many invertebrates, including bees.

    This paper says:

    “If fever first evolved in a common ancestor of chordates, arthropods, and annelids, it would have first appeared over 600 million years ago.”

    http://www.sciencedirect.com/science/article/pii/S128645790001337X

    Local increased metabolic rate is probably done to increase hydrogen peroxide levels (from superoxide dismutation from mitochondria). High temperature also attracts immune cells and triggers heat shock proteins.

  11. Alia says:

    While I agree with most of the post and find it very interesting, I must disagree with the comment about nurses. My mother is one and whenever I came to her and complained “mom, I have a fever”, she would say something to the result “100 is not a fever, don’t fuss”. Of course, when it was 103 and I was getting delirious from a heavy flu, it was totally different.

    Another thing is, my organism is a bit faulty and as a kid I used not to get any fever, even when I was seriously ill (things like bronchitis or angina). Fortunately my mother recognized other symptoms and did not claim “if you don’t have fever, you cannot be ill”.

  12. elmer says:

    I have chronic pain (more-or-less; it doesn’t hurt much at the moment) in muscles involved in breathing, with resulting muscle guarding. When the muscles tense up from pain, I feel tired and dizzy, and it’s hard to think straight. I believe this is because of compression of nerves or blood vessels (a neurologist I decided to see a few years ago did notice that I have no pulse in my left arm when it’s raised above my head). Slowing down my breathing is a big part of managing (not curing) all this. I had to figure all this out more-or-less on my own, though (through reading and trial-and-error). Doctors were of zero help with this, and physical therapy/weightlifting made it worse. But of course I’m just one person, so it’s most likely just placebo. Except that it isn’t.

  13. elmer says:

    …part of the problem being that I have access to all the complex sensory information that my muscles are sending to my brain, and my doctors don’t.

  14. Mark Crislip says:

    My comment was referred to a nurse, my wife, not nurses as a whole.

    My goal is to eventually work James Joyce into a post.

  15. BillyJoe says:

    “yes, 98.2″

    It’s always been 98.2 (36.8 in the proper units!) in my neck of the woods.

  16. BillyJoe says:

    “Fevers are an important, evolved response to infection”

    I always pre-empt my immune systems evolved response by rugging up and keeping as warm as tolerable at the first sign of any infection. I also keep up my morning runs – unless sweats, chills, aches and pains supervene (I take that as a sign from my immune system that I need to rest).
    I wonder if there have been any clincal trials in support of these measures.

  17. Ken Hamer says:

    “It’s always been 98.2 (36.8 in the proper units!) in my neck of the woods.”

    ???

    I always understood the the precise, correct body temperature to multiple decimal places was not 36.8°C, but rather 37-ish°C.

  18. BillyJoe says:

    “…part of the problem being that I have access to all the complex sensory information that my muscles are sending to my brain”

    Yes, it does seem to me that the problem is in your head. ;)

  19. Alia says:

    Well, in my part of the world the correct temperature is supposed to be 36.6°C, while in Russia they claim it’s AFAIK 36.5°C. I guess it’s really all personal and changes in different conditions, as everything.

  20. Badly Shaved Monkey says:

    Mark

    Do you have a link to a summary of the evidence for your ‘hands off the antipyretics” arguments? I’d like to read more.

    As vets we find ourselves, as Harriet says, giving antipyretics to relieve misery, but it concerns us that we are suppressing evidence of the continuing pathology and whether or not we have tackled that properly. I suspect the same would hold for neonatologists who, like us, must want to grasp every available objective measure of disease since our patients are not going to report verbally to us.

    One of the post pointed examples in veterinary medicine of leaving vital signs alone, though involving pain more than pyrexia, is to avoid potent NSAID analgeisia in equine colics while you are still trying to triage them as medical versus surgical.

  21. Badly Shaved Monkey says:

    Oops.

    One of the Most pointed examples in veterinary medicine of leaving vital signs alone, though involving pain more than pyrexia, is to avoid potent NSAID analgeisia in equine colics while you are still trying to triage them as medical versus surgical.

  22. mousethatroared says:

    When I get a post virus asthma flare my main symptom is a shallow dry cough that leads to occassional uncontrollable coughing jags. A rescue inhaler works quite well for this, but occassionally I have been caught without my inhaler. In those cases I have found that a particular breathing methods seems to somewhat fend off the coughing. I exhale, slowly and gently, as much as I am able, then inhale (slowly gently) somewhat less than I am able.

    This is based on something (not sure if it’s true) that I read online about the impaired ability to exhale in asthma coupled with one’s tendency to inhale deeply during an asthma attack resulting in exess air stored in the lungs, thus lowering breathing capacity. (did that make sense? the article explained it better, with diagrams and all). The idea is to exhale more than inhale, hopefully, lowering the amount of air stored in the lungs.

    Anyway, it seems to help fend off the coughing somewhat in a bind. Perhaps it’s just distraction, or maybe it’s that it reminds me to breath, rather than hold my breath, which I sometimes unconsciously do when I’m trying not to cough. I don’t know.

    The inhaler is far better.

  23. daedalus2u says:

    The feelings of fatigue, misery, exhaustion and lethargy during acute illness are “features”, and are important signals that are informing you as to the metabolic state of your physiology. Ignore or mask them at your peril!

    A major pathway in acute infection response is expression of iNOS and generation of very high NO levels. The main function of this very high NO level is to suppress bacterial quorum sensing, suppress expression of bacterial virulence factors and most importantly to suppress formation of a bacterial biofilm on the inside of the vasculature. As bad as bacteria floating in the blood stream is, if they attach as a biofilm somewhere it is at least 100 times worse. That is why sepsis is such an extreme state. Physiology is trying desperately to prevent the bacteria from forming a biofilm and is willing to risk death to do so because if a biofilm does form, then you essentially are dead (in the absence of ID docs like Dr Crislip with antibiotics to kill bugs).

    This very high NO level has the effect of shutting down ATP production via mitochondria in most tissue compartments. There are two main pathways, the high NO level regulates the ATP level to be high (via their combined effect on sGC) and also by blocking cytochrome c oxidase. The high ATP level turns off mitochondria because they are not needed to supply ATP. Instead the ATP is supplied by glycolysis. Unfortunately, glycolysis supplies about 5% of the amount of ATP per glucose molecule that mitochondria do. To maintain the same ATP production rate the vasculature would need to deliver ~20 times more glucose than it normally does. It can’t do this without hyperglycemia (which is why there is hyperglycemia during an infection) and even hyperglycemia isn’t enough. The liver doesn’t have the capacity to produce 20x more glucose, so the muscles turn themselves into amino acids and those amino acids get turned into glucose. Cells use that glucose to make ATP and lactate and then the lactate has to be disposed of by being turned into fat. This is why during sepsis people can lose 40 pounds of muscle and gain 10 pounds of fat in just a couple of days.

    If physiology can’t supply enough glucose to keep the ATP level high enough to keep the mitochondria off, the when the ATP level falls, the mitochondria do turn on, and in the high NO environment of sepsis the mitochondria are irreversibly turned off. This is the mechanism for multiple organ failure in sepsis.

    http://daedalus2u.blogspot.com/2008/06/mechanism-for-mitochondria-failure.html

    The reason you feel so lethargic during immune system activation is so that you don’t waste ATP doing stuff that is not important.

  24. Badly Shaved Monkey says:

    This is based on something (not sure if it’s true) that I read online about the impaired ability to exhale in asthma coupled with one’s tendency to inhale deeply during an asthma attack resulting in exess air stored in the lungs, thus lowering breathing capacity. (did that make sense?

    More or less. I don’t think a physician would describe the air as “stored”, which implies it is helpful. I’d describe it as trapped. I’m no respiratory physiologist, but it seems self-evident that if you can quietly relieve the hyperinflation of your lungs that results from air-trapping then an unpleasant sensation is likely to reduce.

  25. Harriet Hall says:

    @daedalus2u,

    “The feelings of fatigue, misery, exhaustion and lethargy during acute illness are “features”, and are important signals that are informing you as to the metabolic state of your physiology. Ignore or mask them at your peril!”

    OK, but I still don’t think using Tylenol for home treatment of common self-limited illnesses is a significant peril. Do you have any evidence otherwise?

    Pain is an important signal too. I hope you wouldn’t tell a patient in agony from a kidney stone that you won’t give him any pain meds because it would be perilous to mask his symptoms.

  26. mousethatroared says:

    @badly shaved monkey, Yes, “trapped” is a better word for what I was trying to say.

  27. BillyJoe says:

    d2u: “The feelings of fatigue, misery, exhaustion and lethargy during acute illness are “features”, and are important signals that are informing you as to the metabolic state of your physiology. Ignore or mask them at your peril! ”

    Was that in support of my hypothesis?….

    BJ: “I also keep up my morning runs – unless sweats, chills, aches and pains supervene (I take that as a sign from my immune system that I need to rest).”

  28. BillyJoe says:

    HH: “OK, but I still don’t think using Tylenol for home treatment of common self-limited illnesses is a significant peril.”

    Does it actually do much though?
    I’ve never had a viral illness that has caused so much pain that I needed a pain killer. Perhaps I’ve been lucky. Mostly there is mild pain in the muscles and joints that makes me want to curl up in bed and go to sleep.

    “Pain is an important signal too. I hope you wouldn’t tell a patient in agony from a kidney stone that you won’t give him any pain meds because it would be perilous to mask his symptoms.”

    In undiagnosed pain you wouldn’t want to, would you? You might miss a ruptured aneurysm. Or you might miss a drug addict! However, once you’d diagnosed kidney stones – which, I guess shoudn’t be too hard even for a mediocre doc – then, yeah, pile on the pain meds.
    (Hmmm…I wonder how good drug addicts are at faking the pain of kidney stones?)

  29. @BJ, sigh. SIGH!!!!!!!!

  30. DW says:

    “I’ve never had a viral illness that has caused so much pain that I needed a pain killer. Perhaps I’ve been lucky. ”

    Yes, you’ve been very lucky.

  31. @Dr. Hall, are you asking for evidence that a disease is cleared quicker or more effectively by letting it run its own course without intervention as opposed to treating it “symptomatically”? I’d like to see that data too. In fact, it seems rather cruel to let someone suffer when we can easily make them comfortable.

    @BJ, to address your statements and questions:

    In undiagnosed pain you wouldn’t want to, would you? You might miss a ruptured aneurysm. Or you might miss a drug addict! However, once you’d diagnosed kidney stones – which, I guess shoudn’t be too hard even for a mediocre doc – then, yeah, pile on the pain meds.

    :) Again dictating how doctors should practice!!!

    That doesn’t really make sense. I don’t think any doc would treat “undiagnosed pain”?

    Doc: “Hello, BJ, how can I help you today?”
    BJ: “I have pain.”
    Doc: “Ok, dont’ tell me anything else, here are pain meds!”

    This is why we take a history and perform a physical exam and lab tests. I would ask you where the pain is, and you would point to your kidneys, and then I’d ask if it spreads anywhere in your body, and you might point towards your groin. You might also tell me about problems going to the bathroom, or that you’ve had this pain before, and I might run some simple tests on you, such as a urinalysis.

    If you had a ruptured abdominal aneurysm, then you’d have excruciating abdominal pain, you’d have a gigantic pulsating mass in your belly, and you’d probably have a feeling that your world is moments away from coming to an end. I’d sincerely hope you wouldn’t be in an office complaining about this, and that you’d be at an emergency room!

    (Hmmm…I wonder how good drug addicts are at faking the pain of kidney stones?)

    It can actually be very difficult or very easy to identify drug seeking behavior. When they come in for the first time and start telling you how another doctor was giving them Soma and Lortab, but then something crazy happened, yeah, get out. Or the patient has some provable cause of pain, and you say “Ok, we can try Xxx”, but it’s not what the patient wants (Lortab) so they say “I’m allergic to that.” You reply “Ok, how about Naproxen?” and they are “allergic” to that too! They magically are allergic to every medication except for the one they want. You ask them what happens when they take it, knowing full well that they are not allergic, and they say “Oh my stomach hurts”, or if they’ve read a little they say “I swell up.” That can be difficult – you know the patient is in pain, and the medication they want would be effective, but you also know that they are lying about being allergic to the medication that you think is most appropriate.

    For some people, the “culture” of the way they were raised influences their belief about pain medications. Perhaps they were of lower socioeconomic status and were raised with parents who were either legitimately or illegitimately on chronic pain medication. Now this person breaks their foot, and insists that they get Lortab for the pain. You, as the doctor, have experienced the exact same break in your foot and know that it does not hurt that bad, and that you got by without even taking an Advil for it. You tell the patient that such medication is not appropriate treatment for their injury, and now they become furious. They may leave your office, but now they are going to focus on the pain in their foot so much that it will “hurt” them more and more, and they will become fixated on finding a doctor who “isn’t an idiot” and will give them what they “know they need.” Another example for PCPs are patients who want narcotics for their diabetic neuropathy. It’s completely inappropriate, ineffective, etc, but they “know” it works.

    I’ve been cussed out and told what an idiot I am many times because I rightly don’t give out opiods for inappropriate reasons.

  32. mousethatroared says:

    Regarding treating fevers at home for the typical viral illness. I’m with HH, I treat a fever for comfort. The kids get the typical viruses that go around. I figure if they are acting pretty normal and playing some, but have a fever, I don’t do anything. If they are acting sick and complaining of feeling aches, sore throat, headache, I give them Tylenol. It definitely does work for those symptoms.

    A few years ago my daughter got Hand Foot and Mouth Disease, what a miserable virus that is. She had blisters inside her mouth and throat and fever around 104. I feel like the relief that she got from the tylenol helped her drink and sleep better, lowering the risk of dehydration, at least.

    For myself, I see no reason to put up with a sore throat and aches and pains that prevent me from sleeping. The typical virus, for me, seems to last a day or two, regardless of whether I use Tylenol or not. So why not be more comfortable?

  33. Harriet Hall says:

    @BillyJoe

    “I’ve never had a viral illness that has caused so much pain that I needed a pain killer”

    I wasn’t talking about pain; I was talking about misery.

  34. elmer says:

    @skeptical health:

    I like to read http://updates.pain-topics.org/

    One thing I’ve noticed is that the posts that get the most comments (say 10+) are generally on the problem of pain sufferers being denied relief due to the suspicion that they may be “abusers.” And the comments are typically scathing. You might mosey on over there sometime, post a comment like your last one and see what happens.

  35. elmer says:

    Also, to patients: if your doctor is dismissive of your opinion, change doctors.

  36. elmer says:

    Also, if I were in pain, and the doctor said something like “This happened to me (as a doctor), and it didn’t hurt that bad,” he or she would be in danger of feeling some pain that would, indeed, be that bad.

  37. @elmer,

    So what you’re saying is that you would react like a child: you don’t like what you hear so you resort to violence. Well, you’d then be arrested, charges would be pressed, and good luck getting quality medical care in jail.

    Also, we wouldn’t (shouldn’t) say something so submissive to a patient. An appropriate way is “I do not think that medication is appropriate for your condition.” If they continue or insist, they can simply see another doctor. We aren’t required to accept new patients if we think it will be an unproductive relationship. And a patient battling me the first time I see them is certainly unproductive. And we certainly aren’t required to prescribe whatever medication a patient thinks they are entitled to.

    re: that web site. People that suffer from chronic pain lead a challenging life. The bad thing is that usually people suffer from something that isn’t their own fault. They need to also understand that while we have some very strong pharmaceuticals available, we have to be responsible with them. If a pain doc insists that you take the medication as he prescribed, and he urine tests you and you skipped a dose, or doubled up, or whatever, then the patient has to understand that they aren’t following the doctor’s directions and that they can (and will) be “fired” so-to-speak. It sucks, but that doctor’s license and practice is at hand and he isn’t going to risk losing his income and feeding his family because the patient thinks they know better.

  38. elmer says:

    I’d suggest taking the comments on opiods over there, since I don’t happen to use them. Good luck.

    My experience with doctors is they screw up, frequently, then obfuscate to cover up their screw-ups or those of their colleagues. They are infamous for having god complexes – it appears to be part of the culture of doctors, though I don’t know whether the profession simply attracts this kind of person or they become acculturated that way. They are typically contemptuous of anyone who is not a doctor, very much including patients.

    As a patient, I understand that my doctor knows a lot of things that I don’t. But any patient who automatically defers to his doctor’s judgment, or trusts in his honesty or his goodwill, is being foolish.

  39. weing says:

    “My experience with doctors is they screw up, frequently, then obfuscate to cover up their screw-ups or those of their colleagues.”

    Sorry to hear that.

    “As a patient, I understand that my doctor knows a lot of things that I don’t. But any patient who automatically defers to his doctor’s judgment, or trusts in his honesty or his goodwill, is being foolish.”

    Have you ever thought of paying him/her?

  40. elmer says:

    I think we need more research on the analgesic effects of schadenfreude

  41. Note to self: Do not waste time ever replying to Elmer again.

  42. mousethatroared says:

    Sorry this is off topic

    @elmer- I’m having trouble seeing why you were bothered by SkepticalHealth’s comment on drug seeking behavior. Two of my family member’s have serious problems with narcotics, narcotic/alcohol addiction. The last thing my family appreciates is doctor’s who thoughtlessly hand out opioids or powerful muscle relaxants to new patients with complaints of back pain or similar. Maybe they just want to keep the patient “happy” or maybe they want to avoid conflict, or maybe they are clueless. I don’t know, but it is dangerous behavior.

    I appreciate SkepticalHealth being willing to take sh*t from out of control patients. It sounds like he is doing the right thing to me. It has probably saved lives and heartbreak, maybe given someone the chance to get into rehab before something terrible happens.

  43. BillyJoe says:

    SH: “sigh. SIGH!!!!!”

    And then you completely agree with what I said!!!!
    (Well, with a bit more detail)

    SH: “Again dictating how doctors should practice!!!”

    No, just suggesting that doctors would probably diagnose before treating.
    Seems sort of logical.

  44. BillyJoe says:

    BJ: “I’ve never had a viral illness that has caused so much pain that I needed a pain killer”
    HH: “I wasn’t talking about pain; I was talking about misery.”

    Oh. Well, in that case….

  45. BillyJoe says:

    SH: “Note to self: Do not waste time ever replying to Elmer again.”

    :D
    Or you could try a version of my reply:

    Elmer: “part of the problem being that I have access to all the complex sensory information that my muscles are sending to my brain”
    BJ: “Yes, it does seem to me that the problem is in your head. ;)

    He didn’t even try to respond to that one. :)

  46. Haha that’s a good one! :)

  47. LMAO says:

    While people who suffer from genuine chronic pain conditions, it’s clear that @elmer has never spent any significant time in an emergency department… even when I worked in a tiny community-hospital based ED with only eight bays, we had a habit of running a pool on how many drug-seekers we’d see on a Friday or Saturday night. Slow nights always seemed to get a higher number than busy ones. Apparently people who need a fix aren’t willing to wait around in an ED waiting room.

    I personally always looked forward to the endless stream of outlandishly entertaining stories they came up with. One of my personal favorites was the (self-dx’d) UTI pt who had to be fetched from her vehicle in a wheelchair because her pain was so severe that she was doubled over, and could barely walk. She insisted that Demerol was the only thing that would work, and her “regular” doc “always” gives her Demerol. Furthermore, she insisted the UTI was so bad that she couldn’t possibly produce a urine sample. A cath was offered and suddenly a sample became possible. Urinalysis comes back negative. Pt miraculously has no difficulty self-ambulating out of the ED quite rapidly (more like storming)… and, of course, cussing us out all the way to the parking lot.

    OTH, yours truly is one of those who tells doctors/nurses that Percocet has never seemed to do much for me, while Vicodin has generally done the trick (for whatever reason) :D

  48. LMAO says:

    that should say “while I’m sympathetic to people who suffer…”

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