From the President
From the Editor
The Mid-Nebraska Pulmonary Conference
by Jane Wilwerding-Matsui
Requests for Pictures and Slides
by Melody Bero, RRT
Antileukotrienes: Anti-Asthmatic?
by Julie Guida, AS-Respiratory Care, CRT, Nebraska Methodist College of
Nursing and Allied Health
Congratulations!!!
The NSRC wishes to congratulate:
NEW CRTs
Southeast Community College - Wekesser Outstanding Teacher Award
2000 Elections, NSRC Board of Directors
by Mike Stoakes, Nominations Committee
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I hope this issue finds both you and your families doing well. With the coming of a New Year we all tend to reflect back and assess what type of year we experienced. I can truly say that 1999 was a very fulfilling and challenging year, both personally and professionally. As we enter the New Year the our profession will continue to face new challenges. As a 20+ year veteran of the profession, I can truly say that we have accepted those challenges and have seen the profession grow as a result of hard work and the enduring spirits of respiratory care practitioners that truly care about the profession. We can and do make a difference and we are beginning to see increasing evidence of this. The release of the MUSE study, this past summer, demonstrated that we are the only skilled health care professionals who receive comprehensive formal education, clinical training and validated competency testing in respiratory therapy. This has gone a long way with the Medicare reform legislation being drafted. It is our understanding that language noting respiratory competency documentation will be included in Senator Roth's Medicare Reform Bill. This is a major victory for our profession. The AARC and your board has worked hard on this issue. Every chartered affiliate of the AARC played a major role in helping with this effort. We contacted Senators Kerry and Hagal's offices to discuss this issue and ask for their support. The response has been positive. If you see a board member give them a "pat-on-the back, they deserve it for their steadfast work with this issue. The language in the reform bell should help in future years when other health care providers challenge the necessity for using a respiratory care practitioner to provide respiratory care.
Other activities the board has been involved in are: the development of a communication network for members, developing a position relating to registered polysomnographers (RPSGT) as related to performing O2 administration and CPAP titration and joining the coalition "Citizens for a Healthy Nebraska". Citizens for a Healthy Nebraksa is a statewide group organized to address issues related to tobacco use and education in the state. Education and smoking cessation programs funded by the State are the main topics of discussion. I fell that it is important for the NSRC to be a member of this group to provide input as to the direction of these types of programs. Other groups represented in the coalition include the Nebraska Medical Association; American Heart Association; American Lung Association of Nebraska, American Cancer Society, Heartland Division; Nebraska Association of Hospitals and Health Systems; Nebraska Dental Association; Nebraska Nurses Association and now the Nebraska Society for Respiratory Care. As you can see we are in good company!!
As always, if you have any questions or concerns regarding your profession or your Board's activities, please give me a call. I hope that you and yours had a blessed holiday season and a very safe and Happy New Year!!
Greetings and Happy New Year!! I hope this newsletter finds everyone healthy and happy. What a time to be involved with the respiratory care profession. This newsletter contains several interesting (I hope) items.
You may have noticed that we recently began a section dedicated to articles from students. It may seem like a section dedicated only to Nebraska Methodist College students, but those are the only students I have heard from. If you know of other students whom have articles they wish to see published, please have them contact either myself or a board member. We look forward to publishing articles from ALL the respiratory schools in the area.
I am publishing a note from the AARC executive director, Sam Giordano on teamwork. Traditionally, the New Year is a time for resolutions and I am hoping to generate an interest/desire in our members to be a part of the team. If you do not have any time you can donate, then please consider writing to your legislative representative when the need arises. It requires little time and one person can do the actual letter and several can sign it. These letters are often published in the Inspiration or the AARC Times and only require copying and signing. We can, as a team, do great things. A look at recent victories confirms this. As always the information and opinions expressed in the newsletter are those of the writer, not the NSRC.
The Mid-Nebraska Pulmonary Conference, sponsored by Apria Healthcare was held October 19, 1999 at the Regency Inn in Kearney. The NSRC was instrumental in seeing this conference was a success. The meeting provided respiratory care practitioners with seven CEU's awarded by the AARC, nursing CEU's were also awarded.
The day long conference provided information on the following topics: Current Sleep Issues by Dr. Bob Bliecher; Mucus Mobilization by Dr Paul Sammut, Augmented Ventilation by Dr. Michael Perry, Agricultural Lung Disease by Dr. David Cantral, Fifty ways to be a Better Lover and Humor for the Health of It by David Glenn, and Noninvasive Ventilation in the Home Care Setting by Angela King and Matt Garber.
Jame Wiwerding Matsui, the NSRC representative, participated in planning the program and obtaining CEU's from the AARC for the programs participants. The NSRC also provided a booth, staffed by Melody Bero and Patty Bauer, informing participants of the advantages and benefits of NSRC/AARC membership and future offerings.
Apria Healthcare developed this program to provide affordable, quality educational opportunities for RCP's. The NSRC assisted them as providing education is ont of our primary goals. Chris Carfield coordinated the details of the Mid-Nebraska Pulmonary Conference. Congratulations to her and all the other Apria representatives who made this a successfull conference.
The NSRC awarded three free registrations to the 2000 Great Plains Conference on Respiratory Care to be held in May 2000 in Kearney, Nebraska. The lucky winners were: Annette Sholtz of Blair Gener Rech of Omaha Margie Eddie of Aurora
Since the new millennium is arriving, I thought it would be fun to look back over the past decade of respiratory care and how it has changed. For this year's convention, I am planning a slide show to show the evolution of respiratory care. To do this I am asking for help from everybody. Anyone that has slide or pictures I could make into slide of respiratory equipment or staff from years past to the present please contact me. I would greatly appreciate the use of these for the presentation. You may call met at work (402) 445-0600 , 1-888-445- 5488, or home (402) 554-1981 and I will arrange to get them from you. This year we are also compiling photos and information for a calendar to be available at the state convention in May. If you have photos that you would like to see on a calendar and important dates please call Linda Tobin at (402) 731-8700 or fax her at (402) 731-8992 or me at (402) 445-0600 or fax me at (402) 445-0601.
We are looking for photos which reflect the respiratory care's past history. I hope to make this years conference a fun event and with all your help I know I can. Thank you for your participation!!!!
Asthma is a disease that affects 4- 5% of Americans today. This statistic has risen rapidly over the last decade, and the etiology is unknown. Fortunately, medications and techniques for asthma management have improved, and have shown to be very effective for prophylactic use. Within the last 20 years, leukotriene modifiers have entered the asthma management spectrum.
Research on the mechanisms of allergic asthma started long ago, but the spark of leukotriene study was in 1938 by two scientists, Feldberg and Kellaway. Their study involved the reaction of cobra venom on guinea pig lungs. It was discovered that distinct smooth muscle contraction was present. Two years later, two scientists, Kellaway and Trethewie, found that there was a substance responsible for the slow onset of muscle contraction. The substance was named SRS-A, slow reacting substance of anaphylaxis. More studies were conducted over the years, and it was shown that there was a direct correlation with SRS-A and allergic asthma. In the late 1970's, the components of slow-reacting substance of anaphylaxis were identified, and they are now called cysteinyl leukotrienes C4, D4, and E4.
The leukotrienes are produced by different enzymatic activities in the lungs. Mast cells, eosinophils, and alveolar macrophages are primarily responsible for these actions. Not only are leukotrienes strong brochoconstrictors, but they increase vascular permeability, mucosal edema, and mucus production. They have also been found to increase the proliferation of fibroblasts, smooth-muscle cells, and airway epithelial cells. These factors may all contribute to the narrowing airways associated with asthma.
Although all cysteinyl leukotrienes promote the same allergic effects, leukotriene E4 seems to be the least potent of the three. Surprisingly, cysteinyl leukotrienes are considered to be approximately 1000 times more potent than histamine and methacholine in regard to bronchoconstriction.
It is evident that there is clinical importance to treating asthmatics and avoiding the synthesis of cysteinyl leukotrienes. Presently, the use of antileukotrienes in preventing asthma symptoms is increasing dramatically. As health care professionals, it is essential to understand how antileukotrienes work and which drugs are found to be beneficial for asthmatic patients.
Currently two types of leukotriene modifiers are being used clinically : leukotriene-receptor antagonists and leukotriene-synthesis inhibitors. Leukotriene-receptor antagonists block selected receptors, so that the leukotriene is not able to bind, thus decreasing asthma symptoms. The leukotriene-receptor antagonists that are available in the United States today are montelukast (Singulair) and zafirlukast (Accolate). Montelukast is available in the oral form, 10 mg oral tablets, and a 5 mg oral, chewable tablet. Montelukast is given to patients 6 years to 14 years as the 5 mg chewable tablet once each evening, and patients 15 year and older receive the 10 mg oral tablet once in the evening. It can be taken on a full or empty stomach because it is absorbed from the gastrointestinal tract quickly. The drug is metabolized in the liver, and excreted mostly in the feces. The half-life of montelukast is 2.7-5.5 hours with the exception of some elderly patients, in whom the half-life is a little longer.
Zafirlukast is the other leukotriene receptor antagonist currently available in the United States. It is only available in the 20 my tablet form. It is given in patients over the age of 12 years twice daily, 1 hour before meals, or 2 hours after meals. Patients are instructed not to crush or break tablets. The half-life of zafirlukast is 10 hours, and it is rapidly absorbed in the gastrointestinal tract. The drug i metabolized in the liver, and mostly excreted in the feces. Leukotriene-synthesis inhibitors are composed of coumpounds that inhibit either 5-lipoxygenase or 5- lipoxygenase-activating protein, two substances that are needed to complete leukotriene production. Zileution (Zyflo) is the current form of leukotriene-synthesis antagonist being used clinically.
Zileuton is available in a 600 mg tablet for adults given four times daily with or without food. Because zileuton can increase the hepatic transaminase level (AST), the patient's levels need to be measured at the baseline, and monitored on a monthly basis for the first three months of use. After this period, the levels can be looked at every two to three months for the first year, and periodically thereafter. For this reason, the drug is contraindicated in patients with active liver disease and liver dysfunction. Alcoholics must also use caution when taking this drug. There are some drug interactions with zileuton as well. It can increase concentration toxicity in some medications, as well as increasing the effects of beta-blockers. Zileuton is absorbed quickly after oral administration, and is metabolized in the liver. It is excreted in the feces, and may not be removed by dialysis. The half-life of zileuton is 2.5 hours with its peak at two hours. With most medications on the market, there are safety risks and side effects that can occur. Fortunately with leukotriene-modifiers, the risks seem minimal. There are a few side- effects with montelukast, including headache, influenza, abdominal pain, dizziness, dental pain in patients over 15 years of age, and diarrhea, nausea, and infections in children under 15 years. There has been no altered liver function noted in studies of montelukast. In fact, no adverse liver effects have been found in patients receiving montelukast at dose higher than the recommended dose.
The side effects are limited with zafirlukast as well, but can include headaches, nausea and diarrhea. On rare occasions, generalized pain, fever, vomiting, dyspepsia, asthenia, and dizziness can occur. Infrequently, altered liver function can occur, so this should be monitored. One other important facto in the administration of zafirlukast is that the risk of upper respiratory tract infections is possible increased with the patient's use of inhaled corticosteroids. It has been noted that in 3.5-4% of patients taking zileuton, a reversible abnormality in liver function occurs.Each of these types of antileukotrienes had many clinical trials before being released onto the market. In one study, the leukotriene- receptor antagonist, zafirlukast, demonstrated that patients using zafirlukast had a sizable decrease in asthma symptoms, beta-agonist use, and asthmatic episodes in general. It was revealed that the leukotriene receptor antagonist increased the FEV1 by 5 to 10% and if taken with a beta-agonist, the FEV1 increased by 20-30%. Peak flow rates taken in the morning were also shown to increase. Similar results were found in montelukast. Zileuton (Zyflo) has also been found to be a very effective drug for prophylactic use in asthmatics. This leukotriene-synthesis inhibitor has shown to decrease the bronchoconstrictor response to exercise-induced asthma, aspirin- induced asthma, antigen inhalation, and breathing of cold, dry air. As demonstrated, the side effects of antileukotriene therapy are minimal. Although they are not effective in every asthmatic patient, the positive outcomes seem to outweigh the negatives. It is evident that they are effective in improving quality of life in asthmatics by preventing symptoms in general, they decrease the use of asthma rescue medications, are safe to use, and are easy to administer, thus increasing compliance by patients. The cost of asthma in 1990 was over six billion dollars per year, and around 20% was used on drug therapy. With the new leukotriene-modifiers, it is likely that this statistic will decrease substantially in the future. So the question remains, are antileukotrienes anti-asthmatic? Only time will tell.