M: MDI (metered dose inhaler)

M2020Ah…the inhaler. There are SO many different medications (now-a-days) that come in a variety of portable devices; the aerosol, dry powder, soft mist, long-acting/short-acting bronchodilators, steroids, etc. Always, always follow the directions/instructions that you are provided for your medications as quantity, frequency, and type of medication routine is individual; what your friend does is not necessarily what you should do. Also, if you don’t understand how to use your ‘device’, ask the pharmacist or call your provider’s office and get the answers to your questions. I have (too many) patients that come in and, over discussing or demonstration, I find that they are either not taking their meds correctly or they ask me because they are not sure. I cannot, without the medication or instructions, tell anyone exactly how they should be taking their home meds – I can only give generic information. And this is a good place for a link; I don’t usually do this but I found this one and it has some very basic information for some types of inhalers, not all; Communitycarenc *use the link to go directly to the inhaler devices. Also, learn the name of your device – it’s helpful when asking questions of someone who doesn’t know what you take; an “mdi” isn’t the same as a “diskus”.

Don’t rush through taking your breathing medications! It eludes me how impatient some people can be with this routine – it’s for you to breathe more easily, you know…to stay alive? Why hurry through the process, thereby, not getting the most from your (expensive) medications? Make taking your respiratory medication as thorough (and enjoyable) as you might find drinking your favorite morning beverage; keep a good schedule and make it as convenient as possible so you’ll stick to it and not ‘forget’ such as morning and night (before) brushing your teeth or taking other a.m./p.m. medications, middle of the day – around lunch time, or multiple times a day – make it around the same time as other routines. By ‘enjoyable’ I mean think in terms of taking your respiratory medications for your lungs similar to eating food for your body: you need it so teach yourself to appreciate it while taking it. A good time to use a breathing technique is while taking an inhaled medication. I know this may sound idiotic but I notice that some people take their medications begrudgingly, like they resent the fact that they need it – this isn’t a healthy perspective, not good for the soul. We are fortunate (that we/if) we have medications that keep us healthy and functioning at our best.

And now for some inhaler basics: When I am giving instructions on how to take inhaled medications I try to get people to think/visualize about what they are doing, what the body is doing, so the process makes sense, thus, easier to remember. In order for medications to be the most effective, you have to get them into the lungs where it binds with receptors in order to work. What that means is several techniques make this optimal.

A. First you need to exhale before inhaling meds: think about it, if you want your meds to go as deeply into your lungs as possible, you need to take a deep breath and, in order to do that, you need your lungs more empty than full. I’m not saying exhale as much as you can (although some people really like to take their time and exhale fully and that’s okay I’m just saying you don’t have to) but do try to exhale a little more than a typical exhaled breath. Then hold until you have your med/mouthpiece in your mouth before inhaling.

B. Place the mouthpiece of any device between teeth. I see so many people pucker up and place the mouthpiece to their lips, like they’re kissing it. You want an unobstructed route for the medication particles to get to your lungs – place it between your teeth (or gums) and close your lips around the mouthpiece.

C. Inhale deeply, slowly and steadily. Note: I’m giving generic information so follow your mediation instructions because some medication instructions (e.g. twisthaler) state to inhale “fast” and I’m not contradicting those. If you are using a spacer* device (and I always recommend using one unless your inhaler doesn’t allow for it), there will be a whistle or a ‘harmonica’ sound when you are inhaling too fast. The reason for inhaling more slowly is to create laminar flow versus turbulent flow. Your airway has all kinds of surfaces such as the teeth, tongue, tonsils, uvula, musculature, etc. and you want your medication particles to flow smoothly into your lungs. The faster you inhale, the more turbulent that air flow is and within turbulent flow those particles ‘swirl’ around and land on the airway surfaces instead of getting into the lungs. Think in terms of water: a slower moving stream of water flows over surfaces more smoothly but a faster flow of water, such as a fast moving river, ‘crashes’ into surfaces such as rocks and creates the whitewater rapids with spraying water. Sometimes you might notice, if you inhale ‘too’ quickly while taking meds, that you cough, that’s due to turbulent air flow, particles landing on surfaces in your upper airway – causing the cough and, in effect, expelling that medication that you just inhaled; counter-productive.

D. Breath hold. Your airways are naturally moist (as observed when you exhale onto glass or a mirror) and a little breath hold, just 3-5 seconds, when you’ve inhaled medications allows those particles to deposit in the airways.

E. Exhale and wait just a little before your next inhalation of medication. You may hear that ‘you don’t have to wait‘ – and maybe you don’t have to…but, in terms of getting the most out of your medication and making it a positive and healthy routine not to be rushed through, a little pause before the next deposition of medication can’t hurt. In some cases, waiting is necessary: logically speaking, if you are taking a bronchodilator (to open your airways) waiting in between puffs allows the medication to start working so the next puff can go more deeply **OR if you take multiple inhalers and your provider hasn’t specified what order to take them (or they say it doesn’t matter), you want to start with the bronchodilator (e.g. proventil, ventolin): it makes sense in terms of opening your airways first and, if possible, waiting maybe 15 minutes before subsequent medications so they can get deeper into your lungs.

F. Follow the directions for cleaning the device (including spacer). Many people do not do this. All inhalers deliver particulate matter (medication) usually through a small opening (depending on the device) and those openings can become clogged with said particulate if not cleaned as directed.

Well folks, I’ve been sitting far too long; my hands are cold, my ass is numb and my eyes are blurring and I still have today’s “N” to write. I hope you found this informative and, as always –

Breathe safely

*Spacer will be discussed with “S”


L: Lungs

I think it’s safe to say that we all know that the purpose of the lungs is to exchange gases: oxygen to the body and carbon dioxide from the body, we all know the two lungs are both located in the chest, one on each side of the heart and that smoking is not good for them. There is a lot of information about the lungs and I am not going to cover all of it here…I don’t need to – Google knows everything. I am going to share some information about the lungs or related to the lungs that I commonly share with patients.

One important piece of information about the lungs is that they work very closely with the heart – and I don’t mean in physical proximity, although that is a clue as to how closely they work together. The heart and lungs are directly ‘tied’ together via the vessels to and from both, simply put: the blood from the body goes into the right side of the heart (atrium to ventricle) and is then pumped directly to the lungs. Once the blood has passed through the intricate tissue of the lungs gathering oxygen, it is pumped back into the heart on the left side (atrium and ventricle) and from there is pumped throughout the body. In short, the heart is (sort of) two separate pumps co-dependent on each other. A heart problem will create, eventually, a lung problem and vice versa and that is why sometimes it’s hard to determine which came first, or for a patient, what exactly is going on when they are having symptoms.

The diaphragm is the muscle that ‘separates’ the chest cavity from the abdominal cavity but more importantly it is the muscle, the main muscle, that creates 80% of respiration. As the diaphragm contracts it creates a negative pressure within the chest and thereby air is ‘sucked’ into the lungs. When the diaphragm relaxes, air is expelled from the lungs. The muscles between the ribs also contract which brings the ribs altogether up and outward to expand the chest cavity. Inhaling is active, exhaling is passive.

A common problem with ‘shortness of breath’ is a chronically elevated diaphragm, a diaphragm that is not capable of contracting because of abdominal fat. No judgments here as I have my own issues with belly fat so I am going to be blunt. If you’ve never seen one of these shows (I can’t name one, I don’t watch TV but I know they exist) that allow you to watch surgeries let me briefly describe fat: it’s just like on a chicken…except a lot more and it isn’t only between your muscles and your skin (that dimply fat that we can see from the outside) it’s a thick, gelatinous, substance between all your organs…it takes up space, the more fat, the more space is taken up, the less room for your diaphragm to move. When your diaphragm is unable to contract and is constantly pushed upward, your lungs cannot expand, less lung expansion, less air, less oxygen = short of breath.

Truth: if you Google the reason(s) for shortness of breath you’ll get many, many answers such as asthma, chronic lung disease, heart failure, anemia, and even anxiety. I think you’d really have to hunt and then still never find “obesity” and it isn’t because fat is not a contributing factor (probably the number one reason Americans are short of breath), it’s because by the time obesity causes pulmonary restriction, there are bigger ‘medical’ (physiological) issues that can be ‘blamed’, thus, diverting attention from the origin of most of our health issues; taking the responsibility from individuals and replacing it with a disability.

The lungs are not empty balloons that fill with air, they are actually tissue with hundreds of millions of air sacs. The right lung has three lobes and the left lung has two and these lobes are divided again into segments and these are divided again into lobules. Most of your lung mass is at the bases; picture your lungs shaped more like a cone with a concave and angled base, the larger and longer portion of the bases are toward your back. Prolonged inactivity, especially while in the hospital bed, can lead to pulmonary problems, namely atelectasis (when the lower segments/lobes of the lungs start collapsing due to shallow breathing and being ‘crushed’ *so to speak* by lying on them for days)  and the well known ‘hospital acquired pneumonia’.

Prophylactic deep breathing exercises are part of a hospital routine typically following surgery or prolonged hospital stays which provides many benefits: reduces blood pressure, decreases heart rate, decreases anxiety, reduces the amount of cortisol (stress hormone), decreases respiratory rate, increases oxygen in the blood, improves core muscle stability, and prevents atelectasis and pneumonia. There are a few different types of deep (or diaphragmatic) breathing exercises but the key to any/all of these is focus; focus just on breathing, nothing else. So, for example, counting when you inhale (1-2-3-4), breath hold (1-2-3-4), exhale (1-2-3-4) and breath hold (1-2-3-4) *you may count higher if you can but not to the point of experiencing shortness of breath; e.g. the point is not to count as high as you can with any phase of the breathing technique but to focus on each phase of breathing and maintaining control. Also while doing the exercises, pay attention to chest expansion and abdomen distention: while lying on your back place one hand each on your chest and abdomen and, if you are using your diaphragm, you should feel your abdomen rise as well as your ribs expand during the inhalation phase. It may take some time to be able to control your breathing with your diaphragm if that muscle has gotten lax.

Pet peeve: instructions for relaxed/deep breathing techniques containing the words “…let your belly fill with air…” Correction: your lungs fill with air. Your belly ‘rises’ because your diaphragm contracts – which means it descends into the abdominal cavity causing an increase in pressure and, therefore, the abdominal wall distends outward.

And for anyone who says, “I can’t do meditation“…Focused breathing exercises is a form of meditation; if the mind wonders, which is a little hard to do if you are counting with each phase of the cycle, just refocus and resume counting and feeling how your body responds during the exercise. If you can sit (or lie down) for a five or ten minute breathing session a couple of times a day, you’ll notice that you are better able to control your thoughts, reactions,  and stress – then it will become easier to do and you’ll want to use this exercise multiple times a day like when your waiting in the grocery line, delayed in traffic, getting irritated by a co-worker/boss/kids, or having evil thoughts 😉

If through reading any of these A2Z posts you have questions, feel free to ask.

And as always, breathe safely.


K: kyphosis

#AtoZChallenge 2020 Blogging from A to Z Challenge letter KOn occasion, when a provider has run out of therapies or medications to help someone breathe easier, I am asked for suggestions. First I want to say that I never get used to medical people who just can’t grasp the idea, in real life, of mortality; the breakdown of body parts and organs to eventual death. I am not exaggerating when I say that the facial expression of providers when informed that ‘there really isn’t anything else we can do’ is that of childlike total incomprehension, like when they first learn there is no Santa Claus. Many of them, probably through the medical school You-are-a-God theme, almost always hold out some carrot of hope of finding something, some-way of ‘helping’ someone stay alive…well beyond the natural expiration date. This isn’t the purpose of my “K” but it’s kinda related.

On more rare occasions, I’ll have a mature patient that has finally reached a point that they are having increasing shortness of breath; not any obvious problem like a pneumonia or an exacerbation of an already existing pulmonary process. If I am able to perform auscultation (listening to the lung sounds) while standing behind them I try to note the spine – especially in older patients. One reason for this is kyphosis, a curvature of the spine that produces a ‘hump’ in the upper spine (causes can be broken vertebrae, osteoporosis,  lifelong poor posture or repetitive stress on the back or back muscles)  or, kyphoscoliosis, which is a curvature that, looking at the back, forms a C shape (causes can be congenital such as spina bifida or infections such as vertebral tuberculosis). These are abnormal curvatures of the spine that, if severe enough, will cause breathing issues.

The spine has a natural subtle S shape (from a side view) wherein the organs function normally but in the case of kyphosis, the S shape is more exaggerated and the lungs can become, over time,  compressed leading to lung restriction, sometimes even collapse of effected lobes. [the same is true for kyphoscoliosis, just a different curvature]. Depending on the reason for the abnormal curvature, there are some solutions that can range from exercise to surgery.

If you are able, and I’m no doctor, I’ve provided a link to a site with some “easy” exercises for spine health. And that closes it out for my “K” today. As always, breathe safely.

Linky Party to Quilting Patchwork Applique for other “K” posts





J & SoSC: joint and jackson rees bag


I’m trying to stick to my theme for the A2Z challenge because the one day that I strayed I wrote the worst post of the challenge.  “J” being a difficult letter for me to fit into my theme – except for Jackson Rees Bag – and using Linda G. Hill’s SoCS, I decided that I’d use ‘joint’ for the joint statements that are disseminated throughout the affiliated hospitals and clinics of the Mother Ship, D-HH (Dartmouth Hitchcock Hospital in Lebanon, NH). These statements/emails are daily, keeping us all abreast of the ongoing information about Covid-19 and what the organization is doing about it. There is usually a reminder somewhere near the end of each statement clarifying that all does not apply equally throughout each facility – which should be obvious when it comes to parking or where to enter the building but I guess being ‘clear’ can’t hurt. The point of these joint statements is that we all carry out policies the same – another obvious.

Re: Jackson Rees Bag.

I didn’t and don’t really want to go into detail with this (being a SoCS post as well) but it does begin with “J” and it is related to hospital/health/respiratory so, here goes:

A Jackson Rees Bag is also called an anesthesia bag. Both ambu and JR bags are used with a gas such as oxygen to assist or supply each breath to a patient. Unlike an ambu bag, which is made of a more stiff plastic that can be squeezed but pops back open regardless of a gas flow, a Jackson Rees Bag is a very supple, limp and smaller bag that needs a constant flow of gas (oxygen/nitrous oxide) to keep the bag inflated while gently squeezing it to supply ‘a breath’ via an ETT to a patient. These type of bags are used in the OR and for assisted breathing for a newborn/infant. Another difference between the two bag types is that the flow-dependent JR bag needs a pressure gauge to measure the pressure applied with each breath – especially when using with a newborn – to avoid any trauma to the lungs.

That’s about it for this posts’ topic. I’m going to go outside and enjoy the much appreciated sunshine available. I hope you all enjoy your weekends and, as always,

Breathe safely.

P.S. Don’t forget to check out these beautiful quilt ideas from Quilting Patchwork Applique


I am tired today.

This “H” post will have to wait until later…maybe while I am working the night shift.

*to be continued

And now for the rest of the story:

I got to work last night in a timely manner but I kept thinking it was morning even though the sun was in reverse; the sky had that same sunrise/sunset appearance with the pinks and oranges but in the west. My boss was the therapist du jour yesterday and since our new schedule went into effect I hadn’t seen much of him and when I have seen him I can tell this whole virus issue is taking its toll. Everyday there are subtle revisions to what we do or how we do it and being on the bottom rung, I think, is easier than being in the middle – responsible for instructing the bottom staff. He doesn’t tolerate bureaucratic shit well. I think our organization is doing an excellent job but….BUT…it’s like any other form of governing: people at the top are calling the shots for people at the bottom and it usually doesn’t work out all that well. You all know what I’m talking about: having someone who doesn’t DO the job tell others how to do it…and then they don’t always listen to constructive criticism because that means that they have to revise the p to accommodate what they didn’t realize they didn’t know. Anyway, my boss starts flinging the F-bomb around, which he doesn’t usually do so it’s kinda farcical, and I am thinking it’s a good thing our office got moved to the furthest dungeon so no one can overhear him.

Before he left he said that the ED is going to run through (another) *intubation scenario and then I’d need to secure the equipment so now I’m immediately on alert to be available for this….again. I could tell he was glad it was time to leave and he didn’t have to deal with it – and I was glad for him because I like the guy and I feel for him. So thinking about doing this again got my dander up and I was carrying on conversations in my head about having done this already – several times – and I’m not going to do it again, blah blah. I went about my business on the floor and while there, sure as shit, the ED pages me to call – which I didn’t do because I was with a patient so I stuck my head out the door and asked someone at the desk to do it for me. No hurry, they just need a ‘red lock‘ (it’s a plastic lock that can be ‘broken’ when we open a code box or med box) was the response.      *intubation will be “I”

Let me explain:

The ED staff (namely physicians) want to rehearse doing emergent intubations so, considering our numbers – one RRT on each shift – I’ve done this multiple times already and even I am sick of it. There is nothing new about intubating patients so I don’t understand all the rehearsals; it’s a few people who are anxious and getting paranoid and it’s causing more tension than is really necessary. The only thing that is different is the PPE, however, having said that, we are supposed to use PPE with intubations anyway (not airborne but still, taking precautions) but, over time, people get lax with following procedures. Now that following a procedure to prevent the spread of a potential deadly virus is paramount, I see staff watching videos on their phones (which have exploded online) ALL THE TIME. Following this the theories as to what we should do or not do start flying and next thing I know people are all doing things their own way because it’s comfortable for them. I’m not saying it’s wrong or bad or dangerous…just different. And this is the crux of my boss’ frustration…people are making things more difficult than they need be because THEY are afraid.

So…my point: I had to repeatedly remind myself last night to be a team player, to be patient, to use this opportunity to rise to the challenge, to do my best to alleviate anxiety by being calm and cooperative and reasonable. I had to tell myself that when this is all over with (this year) that I don’t want to look back upon my actions/reactions and feel like I could have done better. I want to do my best now and that means that I need to lower my expectations (not a bad thing) and not allow my fatigue or frustrations guide my behavior. This too shall pass but meanwhile let me be of assistance and not a hinderance to all staff who are also frustrated and anxious and fearful of what might happen. Let me hold my shit together.



Intubation is the process of inserting a flexible tube through the mouth and into the lungs (specifically the trachea) so a patient can be placed on a ventilator (not respirator). Most times – most – there is enough time to prepare for the procedure even if that means that we use an ambu bag and mask to breathe for a patient while the appropriate equipment and medication is assembled. The process of intubating someone is relatively quick depending on the reason for intubation and within the last decade providers have had the technology to visualize during insertion to minimize the number of attempts before a successful intubation.

A laryngoscope is a short handle with a folding blade (think metal, curved tongue depressor) with a small light and, nowadays, camera that is inserted into the oral airway (mouth) to the base of the tongue. The provider uses a slight lifting motion on the handle of the laryngoscope and this pulls the base of the tongue upward, revealing the vocal cords below (or down lower in the airway); it’s between these two cords that the ETT (EndoTracheal Tube) is inserted. The laryngoscope is removed and the the cuff , a “balloon” near the end of the ETT, is inflated, keeping the air/oxygen that is pumped into the lungs from escaping around the tube and keeping any fluids (such as stomach contents and saliva) out of the lungs. The end of the ETT protruding from the mouth is what is attached to the circuit of the ventilator, which is the machine that pumps a certain volume of air and oxygen into the lungs.

Medical Malpractice Verdict Reduced by Appellate Court from ... Many times on TV we see a patient attempt to “pull the tube out” and everyone rushes to the bedside to prevent this. The idea is that, obviously, we don’t want the tube that is assisting breathing for someone removed prematurely. But another reason is the cuff; physiologically the cuff is below the vocal cords, inflated like a balloon, and pulling a tube out without first deflating the cuff can cause permanent damage to the vocal cords.

An ETT is supposed to be ‘short-term’ – if someone requires artificial breathing for longer than (typically) two weeks, a tracheostomy is required (that’ll be “T” post).

Breathe safely.

G & FPQ – and all that

Are you the same person on your blog as you are in real life? Do you like yourself more in the virtual world than you do in the real world?

#FPQ – See the background story to this question before you answer.

Before I launch into my post, which will have little to do with respiratory, health, wellness nor any other focus within my ‘themed’ wheelhouse…I just want to say…

Good-Fucking-Grief! Some of the stuff I am reading and hearing about politics in the last few days, I cannot imagine how any sane person, who has been following the ‘snooze’ and seeing what “our government” is doing while the population of this country is trying not to die and has been ordered to not leave the house or congregate in groups, has not decided to become a martyr for their country and formed some sort of militia group and bombed the fucking white house. That’s all I have to say about that.

Am I me while I’m here in Bloglandia? Yes. I usually say stupid shit (see above), stuff no one really cares about or even understands; I march to my own disynchronized drum-beat without even noticing other people; I can be coherent and informative when my mind is focused on something but otherwise I just spew whatever is crossing my mind and regardless of who, if anyone, is listening. I know I am mostly not taken seriously when I am NOT invisible – which, considering my age, gender, physical characteristics (butt-ugly) and haircut, I may as well be wearing the Cloak of Invisibility – which I have come to love, BTW.

I have had uncharacteristically perfect weather the last two days off so I’ve taken advantage and done some grueling outdoor work (and, therefore, NOT been blogging -or reading- the alphabet challenge)  and I’m not sorry. I may, for shits-N-giggles, play catch up even if it’s not the correct day or I may just let it all go – doesn’t matter as I may be dead in a month or so (probably not but, hey, you never know). I suppose I, no – WE, should all take advantage of the lawful ABILITY to speak our minds here or anywhere as it seems very soon that may go the way of our right to vote by ballot if we need or want to, the way of meeting in public in groups, the way of leaving our house to travel or walk where ever, whenever we want, the same way of going to the hospital and having life-saving equipment or even staff to care for us, the way of a woman’s right to her own body or the right to choose, the way of equal rights for black people only on paper, the way of clean drinking water and clean air, the ability to work and/or make a living wage to pay for a home, food, utilities, etc., …

Anyhoo…I am really feeling fine. I just had to rant a little. I am becoming more and more aware of how the book of Revelation and today’s world seem to be merging as one. This does not invoke fear in me; the common denominator for us all is death. Knowing that to be the truth, anything that happens before then that may or may not lead up to death in the greater numbers is in alignment with the prophecy of the last days. If this pandemic (let’s call it what it is: plague) repeats itself or is followed by some other deadly micro-organism, killing off millions of people and leading to hoarding & food shortages, riots, brother against brother, love of the greater numbers cooling off (or something like that, not a quote), governments in complete dysfunction with ensuing chaos and the rich distancing themselves to save themselves…well, so be it. I’ll just pop me some corn, butter it up and watch the show. It’s not like we haven’t been warned, it’s not like we don’t see the handwriting on the wall (what’s going on right in front of our eyes) and going about our life as usual, it’s not like history has NOT had some form of this very thing before to be ignored by many, following along like sheep to the cliff edge. I really do not feel bad about all this insanity because we have brought this very situation upon ourselves; our obsession with ‘reality TV’, with ‘celebrities’, with getting rich quick, with not caring about other people – ME FIRST, with numbing ourselves with TV/electronic devices/alcohol/drugs/sex, not daring to speak up on behalf of someone else that does not look like us, putting our heads down and flying under the radar lest we become the object of ridicule, bullying, ostracization, and not fitting in, BLAH, BLAH, BLAH. We deserve no better than what we have and if we don’t like what we see then we need to re-evaluate what we do and don’t do in our every-day lives and decide to make a change.

BTW: all this news about the primaries: IT’S THE GENERAL ELECTION that will really count…well, as much as our individual vote actually counts anyway – which is not much considering that Hillary actually won in 2016 but that didn’t matter.

Okay…I gotta get my ass off this couch and do some laundry, etc. before the day is done. Stay safe everyone – and by that I mean, in addition to keeping your distance from anyone else – stay away from the friggin’ news so you can remain SANE and emotionally healthy in this insane world.


After working the weekend: 12 hrs Saturday & 24 hrs Sunday – Monday a.m., the sun was finally shining on my drive home. The transition from night shift to day shift sucks so I try to stay busy on that day so I go to bed tired and have my ‘normal’ days off. Today, because the sun was finally out on MY day off, I felt energized. I needed to do something outside but what? I made a couple of eggs for breakfast and then took the dogs out for a walk in a (sunny) cemetery and read the headstones – so old. So many children died young in the late 19th century early 20th century!! Entire families were wiped out, sometimes five children under the age of 5 years old leaving the poor parents without any progeny. This particular little cemetery in town has the distinction of President Pierce’s burial place (and wife and two young sons, both died as children) enclosed (with other headstones) in a small fenced off portion of the cemetery. After arriving home I sat on the deck with a coffee observing the back yard with the overgrown embankment; – sigh – nature always encroaching. I decided while the sun was out and it wasn’t hot and humid (the worst weather on the planet) that I’d get out my electric chainsaw and cut down some saplings to allow more light and better growth of certain trees. By 4:00 I was done, tired, feet hurt and I had a tree tops toppled in my backyard that I thought I’d save for tomorrow. I like the shade that these trees provide but the foliage of so many saplings makes it too dense for any one tree to grow properly. There was also a lot of dead branches, etc. that needed to be cleaned out. I don’t particularly want to see my neighbors back yard any more than they probably want to see me in mine but I feel good for having done the physical work. After all that I bough a six-pack of Sam Adams and soaked in my hot tub in the waning sunlight with my Pandora. Later, pizza, movie, bed.

I am grateful for – finally – a sunny day. The sun energizes me to work outside, burn off some calories and get some Vit. D.

Stay safe everyone.


Humans produce droplets when talking, coughing and sneezing and these droplets can contain cells of the immune system, epithelial cells (which are barrier cells like skin & blood), physiological electrolytes within mucous & saliva, as well as ‘germs’ such as bacteria, fungi and viruses.

The droplets vary in size, content and how long they remain suspended in the air. For respiratory purposes, a “droplet” is a particle that is 5-12 µm (microns) in diameter and to give you an idea of how big that is; one human red blood cell is 5µm in diameter. Droplets this size tend to “fall” to the ground/floor (or other surfaces) via gravity and, therefore, if one is at least three feet from someone talking or coughing, transmission of a potential infectious agent is minimal. Contagious infections that are considered droplet are the common cold, influenza, pertussis, mumps and bacterial meningitis. Direct contact is when a susceptible person comes in physical contact with an infected person (host) or in contact with a host’s oral secretions (by standing closer than three feet when a host coughs or sneezes, thereby, inhaling those droplets). For droplet precautions a simple surgical mask is used (by healthcare workers) along with gloves/goggles. Indirect transmission is when someone contracts an infectious agent by touching a surface where droplet has landed (transmission characteristics such as how long an microorganism can live on a variety of surfaces vary depending on the microorganism), therefore, attention to cleaning/disinfecting surfaces that are frequently touched is advisable along with frequent hand-washing.

Droplets smaller in size, <5µm, are called ‘droplet nuclei’ and these are the particles that can remain suspended in air (airborne) and live outside a host for longer periods of time, depending on the microorganism, therefore, one can contract an airborne disease long after the host has left the vicinity. Tuberculosis, measles and chickenpox are a few examples of transmittable diseases that are airborne and require (healthcare workers) the use of an *N95 mask (which requires a specific procedure to *’fit-test’ that the mask will work for you. I did not pass my fit-test for an N95 mask, so I am required to use…) or a PAPR (Powered Air-Purifying Respirator).

If a droplet precaution patient requires certain procedures such as intubation (inserting a ‘breathing tube’), bronchoscopy (for lung biopsies), administration of nebulized therapy, disconnecting the patient from the ventilator, CPap and BiPap use, CPR (cardiopulmonary resuscitation) or manual ventilation via an ambu bag (what you typically see on TV when someone is squeezing that bag over someone’s face), airborne precautions are required.

The information being relayed from the CDC and WHO about the novel coronavirus and/or Covid-19 is ever evolving and sometimes seems contradictory but we need to keep in mind that the efforts to determine the characteristics of this ‘novel’ virus have really only been concentrated in the last 2-3 months when it became more apparent that it is a very contagious and a very deadly virus. And, as viruses go, it’s ever evolving (e.g. influenza can evolve from the time it ‘starts’ in the south to the time it appears in the northeast). A most recent brief (3/20/20) from WHO states that, based on available evidence, it’s recommended that people who care for covid-19 patients use droplet and contact precautions. WHO recommends airborne precautions under circumstances where procedures generating aerosol or support treatment are performed (see previous paragraph).

There’s also been mixed messages/information regarding non-infected people using masks and, personally, I think some reasons are: to avoid depleting supplies and to avoid increased fear on behalf of the general public. Here’s my personal opinion: anyone who’s health is compromised by a pulmonary condition such as asthma, chronic bronchitis, emphysema; anyone who has a cardiac condition; or anyone immunocompromised; or anyone who just wants to be sure that they stay safe &/or keep their family safe – use a mask or any face covering. Almost any barrier between your mouth, nose, eyes is better than no barrier.

Breathe safe.






A CPap (Continuous Positive Airway Pressure) device is a small machine with a hose and face mask or nasal mask used by some people while sleeping and has become more common in the last decade – I’ve even seen it used on TV programs, sometimes as shot at humor but more often it reflects ‘typical’ life. Over 25 million Americans suffer from some form of OSA (Obstructive Sleep Apnea) and about 60% require a CPap unit to sleep well. But sleeping well isn’t just about getting a good night’s sleep for some people, it’s about physical and cognitive health. It’s about staying alive longer and having a better quality of life.

Apnea is when one temporarily stops breathing and the most common form of apnea during sleep is obstruction, when the throat muscles intermittently relax and collapse the airway causing snoring, a key sign of OSA. The duration and frequency of these apneas throughout sleep vary and most of us at times have some interruption of sleep with snoring (not to mention other people trying to sleep with a “snorer” in the room) and it isn’t life threatening. But many people experience such frequent interruptions and longer durations of apnea that it becomes a serious threat to their health.

Sleep disturbances cause one to wake up in the morning feeling that they haven’t slept at all…and it’s true. During sleep we go through repeated cycles of the same phases in sleep and when these phases of sleep – when the brain is actively trying to create and retain memories, engaging neurons, making bodily repairs, boosting the immune system, and more – are repeatedly interrupted the body does not achieve the levels as frequently nor for as long as it needs. We all know how it feels to be deprived of sleep; we feel tired, we’re irritable, we can’t remember as well, and we can’t think as well. Imagine putting the body through this cycle every day.

Another sleep disorder is hypopnea; abnormally shallow or slow breathing that causes pO2 to decrease. I don’t think I need to elaborate on the importance of oxygen.

A sleep study done by a certified/registered polysomnographic technologist done at a clinical site is a necessary evaluation of what takes place during the (attempted) sleep. Sleep evaluations are complicated diagnostics measuring each phase of sleep; respiratory rate, depth, or cessation; heart rate; how much oxygen is in the blood or disruptions in that level; and more. Once the study is done, a provider can order a CPap unit with a specific setting for the patient and directions should be followed, namely, USE IT.

The setting is a pressure, for example 10 cmH2O (centimeters of water pressure), and this pressure is the minimum required pressure within the airway to allow it to remain open even when the throat muscles relax. Each person requires a different minimum pressure and this is determined by the sleep study. By using the device, creating a patent airway while sleeping, the body is allowed to continue through all sleep cycles without disturbances and subsequently one achieves more optimal rest, is less tired the next day and can function better.

Many people object to using a CPap unit for a myriad of reasons but my response to these objections is this: adaptation is the key to a more successful and full life; no one gives wearing glasses or a hearing aide a second thought anymore, wheelchairs, prosthetics and portable oxygen is becoming a more common site in public, why would anyone NOT use a CPap in their own home if it means being more alert, clear headed and feeling better not to even mention alleviating some other health issues such as diabetes, hypertension and cardiac arrhythmias? Give it an earnest trial, wear it every time you sleep for a month and notice if you how you feel. You will quickly become accustomed to it, it will just be a part of what you do in your life and you (and your partner) will get much better sleep and enjoy an improved quality of wake hours.

If it’s a ‘fit issue’, try different masks (note: if you opt for a nasal mask or nasal pillows be sure to use a chin-strap. Wearing a mask over just your nose and sleeping with your mouth open is completely useless; the pressure required to keep your airway open is now flowing out your open mouth) or different head-gear. Be sure to follow instructions for cleaning the tubing, the mask, filter & humidifier, if you have one – cleaning the equipment is commonly overlooked/ignored and it’s dangerous because bacteria love a dark, moist place to live and grow and remember, you are breathing through this equipment, you don’t want to be inhaling bacteria.

Breathing is necessary for life. Breathe safe.

As always, thanks to Frederique for the linky-party