PILOT for Pulmonary Health


Parents recording. Yep. All right. Good afternoon. So I am happy to disappoint this gentleman right here. I do have a set plan but I can straight from it if we have to. My goal for this session is for you to leave with something you can use right off the bat and there’s a lot of stuff that you can use right off the bat. The people don’t think that we get to spend a lot of time with patients and very often that time is wasted to talking about things like whether how the medics are doing, things like that. So every interaction you have with a patient is a chance to further indoctrinate them into your belief system and into taking better care of themselves. So how many people here would say that they are at their peak in terms of their level of practice right now?



So in other words, let’s say like on a scale of one to 10 how many people are at a 10? We’ll say 10, nine, eight, seven, six as far as maximizing your time with your patient because everybody wants more time with the patient, right? Everybody wants more time. Everybody wants more visits, everybody wants more and more and more of that. But what I would say is this, we have to maximize that time, right? So if I give you more cups, but each cup has less alcohol, just kidding. If I could get more cups and each cup is like half full, then that’s a waste of our time. So what I’m going to try to teach you today, I was given a bunch of slides that I have to talk about for like 10 minutes. Then I can talk about all the things that nobody talks about, but that really work and can really make a difference.



So let’s talk. Alright, this eat 50th. Don’t forget to fill out this name three and 14 conditions that are crucial to risk stratify during your eat. Okay, so let’s talk about five key components of ultimate pulmonary wellness. A single best exercise for pulmonary wellness, ATS, ERs. So American thoracic society, European respiratory society, home and air rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient tailored therapies that include but are not limited to exercise training, education and behavior change designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the longterm adherence to health enhancing behaviors. That sounds obvious, right? But it’s not always like that. Okay. It’s not always a comprehensive evaluation. It’s not always a patient tailored approach. Right. How did people here work in rehab? How many people here work in lifestyle or teaching a patients?



Okay, everybody should you raising your hands for that? Because we should be teaching patients all day, every opportunity to talk to a patient, to interact with a patient. And it’s like, how’s your daughter? How’s everything? How are you doing today? I like your hair. Right? Or I could have said, Oh, I’m glad to see that you’re eating a little bit better today. Okay, I’m wrong. I’d rather you do that. So think about your time with your patient as very, very valuable. And when it comes to communication, there’s three types of communication. So there’s bad communication, which is obviously bad, inappropriate, it’s offensive. It’s things that you shouldn’t say as juvenile. And there’s good, there are comedic communication and you’ll see two people and they will say the same exact thing to a patient and one the patient will say what? I’m sorry I didn’t hear you.



Why is this guy talking to me? And another one who’s a gifted communicator is going to say something to occasion and they’re going to find out through conversation that they have the same cousin in Manitoba. So think about every opportunity as a way to communicate with your patients. So this is ideal. It doesn’t happen in every situation. And we know that when it comes to lifestyle and wellness and rehab, there’s huge variability from the program. Goals, control and alleviation of symptoms, control, alleviate symptoms, improve activity, Toms, promote self reliance and then attendance, decreased need for good resources, improved quality of life, improved treatment adherence and acuity tasks. That isn’t the goal isn’t, shouldn’t this be the goal of every single thing in healthcare? Yes. So it’s written up, but this should be the goal for life, right? Evidence based guidelines. This is all right here.



I will make this available to you on video. Okay? You will see my slides. So don’t feel the need to do this. This stuff is all out there. Six to 12 weeks long wears off in better lifetime of better session should occur two to three times weekly. 20 sessions may include supervised or unsupervised. This is the basics, okay? But again, variability from program to program. Assessment, intervention, education and educated. Patient is our greatest ally in taking care of themselves. Exercise, of course, nutrition, psychosocial, oxygen assessment. But let’s talk about this. Okay? How many people spend time on each one of these things with their patient? Nobody. You did? You do raise your hand high if you do. Okay, so everybody should be talking about this stuff, right? This is what it is in today’s healthcare society, especially in the U S 90% of it is medication or procedures, right?



And then on the way up, have a little try to eat a little better, lose a little bit of weight. That’s a problem. Okay. So now I want to talk about introduction to pulmonary rehab. So there’s a lot of talk and I can’t believe there’s even as much talk about it, but there’s a lot of talk in the community about maybe one of the reasons why people don’t go to pulmonary rehab is because the name rehab is a turnoff. Now that doesn’t make sense to me. It seems like if you can explain it well enough that that shouldn’t be an issue. So our, our name is pulmonary wellness. It has been for 21 years, but we have to take a lifestyle approach to things. Okay. They say that less than 2% of the people that could benefit from pulmonary rehab yet pulmonary rehab. Why do you think that is?



Alright, if you’re awake, raise your hand. Alright. Alright. So access insurance, no programs in this city. Okay. Up until recently we had five programs in the city. We had NYU, we had Beth Israel, we had Roosevelt, we had Columbia, we had pulmonary wellness and rehabilitation center. Roosevelt closed, Beth Israel closed. We have NYU, we have Columbia, we have the pulmonary wellness rehabilitation center for a city of how many millions of people with respiratory disease. So no one can get. That’s a serious problem. Okay. And it’s because insurance doesn’t pay for it. You only get a certain amount, blah, blah, blah, blah, blah. Serious problem. Serious. Is there an emergency? I’m sorry, could you just excuse me for one second please. Barry, take over. Sorry. Sorry.



My name is Barry. I’m the finance manager. I do apologize but he didn’t have to take that. Everyone please stand up one time. Stand up. Yep. There we go. [inaudible] Alright, so engagement is very important. Okay. Why is there no adherence? Because half the stuff is boring. Half the stuff is not fun. Half the stuff is not interesting. Half the stuff is done in a very, very super official way or in a way that’s too high. Right? In a way that’s too high level. Now think about this. Okay. What makes somebody interested in what you did? What makes someone interested in what you do? Often when people are diagnosed with a chronic illness, and it doesn’t matter if it’s CLPD, it doesn’t matter if it’s pulmonary hypertension, it doesn’t matter if it’s funny that you’re actually listening, I’m dressed like this. It’s still being taken seriously. Awesome. COPT pulmonary hypertension, pulmonary fibrosis, right? They go online and the first thing that they read is you have a chronic progressive disease that there’s no cure. It’s going to get worse. You’re going to get more short of breath and then you’re going to die.



It blows your mind. And very often when people are diagnosed with a disease, they become these kind of unifocal, monochromatic, colorless versions of themselves that are completely devoid of any type of art, fashion, color, music, theater, et cetera, et cetera, et cetera. We live in New York city where people who are 85 90 years old or more contemporary and doing more things than the people who are 25 years old and their lives become about going to the doctor, getting a test, taking the medication, it’s cetera, et cetera, et cetera. And they lose themselves. And so it’s really important, okay. That as clinicians and clinicians, we also can become unifocal. You’d be like, I’m an RTT, I’m a PT, I’m a doctor. This is what doctors do. This is what nurses do. You know, you gotta be a person and you gotta address the person and you have to meet the person where they are to engage them. And you have to have multiple tools in your belt to engage them so that you can give them multiple tools in their breath, in their, in their repertoire to address the problem. Now, what’s the biggest problem? That’s 90% of our patients have?



What? Compliance. What else?



Bueller. Bueller. Anyone not educated about, let’s talk physically first. Why do people come to us?






That miserable shortness of breath, right? Everybody comes to us and he’s short of breath. It doesn’t matter if they’re asthma, COPD, emphysema, chronic bronchitis, pulmonary hypertension, pulmonary fibrosis. That miserable CLPD is what gets them all. So there’s where we have to intervene with this, right? So what’s going on here? This lady is walking up the subway stairs with her oxygen and she gets grabbed. But you got here long land now, that miserable sob and he goes, let go. I’m right here. You son of a bitch, man. Where did you come from? Nevermind that. Put this nice lady down so nobody gets hurt and say, you said, Oh my God, I’m going to die. What are the three things that we hear most often? Walking up the stairs, right? Subway stairs, walking uphill, running for the bus. You know what that’s called? That’s called the New York city pulmonary triathlon. Walk up stairs, walk up the Hill, run to the bus. Right? You could do that. But this is what people talk about over and over and over again. Now let’s think about that. Okay? Let’s think about that. This is one of the most important things you can tell. You can learn today.



Breathing is multifactorial and what do I mean by that? There are many, many factors that are involved in how well or how poorly we breathe, right? And if you have CLPD for 20 years, then people set up, here’s your COPD, you have pulmonary, there is a pulmonary, there’s your pulmonary fibrosis, right? But maybe it’s not that right people, you go online. I have a 13,000 person Facebook group. Can people go, you know what? Lately my toenails have been hurting a lot of, I see OPB you attribute everything to CLPD or pulmonary hypertension or pulmonary fibrosis, et cetera, et cetera, et cetera, but how do we know this is true? Has anybody ever had a patient who comes to them maybe six months or a year later and they say, I’m much more short of breath, but you do their pulmonary function tests completely unchanged, right?



Where somebody says, you know what, I got much better pulmonary function tests completely unchanged. If you read the classic literature about pulmonary rehabilitation, what it’s going to say is that people feel better. They can do more, but there’s no improvement in pulmonary function. I don’t believe that. As a matter of fact, I don’t have to believe it because I know you can improve pulmonary function in many, many people, and I’m going to tell you why it doesn’t improve in many people and what a lot of programs are not doing right, but keep this in mind. Keep it in mind that there are a lot of things that will make you more short of breath. So if somebody comes in and say more short of breath, what’s different? Are you taking your medicines? Yes. You’re exercising. Yes. Doing this. Wait a second. Wait a second. Did you put on any weight?



So yeah, I think I’ve put on about 20 pounds. Okay. So anybody in this room, if I say here’s a bowling ball, this guy is fit. Here’s a bowling ball. Carry this around all day, every day with you hanging off your ribs. Right? Because every time you need to take a breath, you have to lift that bar. So who’s not going to be short of breath going up the stairs and that Bowman, but he’s not going to be short of breath when they walk up a Hill with that bowling ball. Who, who’s not going to be short of breath when they run with that bowling ball for the bus. So the thing is, any political fans in the audience, you can not, I’m going to pull it up anti-fat now, I used to love politics. I hate it now. But James Carville, okay, Clinton’s main campaign management had this great sloping keep the main thing, the main thing.



Okay? And you have to look at your patient and you have to say what is really making this patient short of breath. You ever see someone who’s got limited, not really bad disease, maybe mild disease, but symptomatically it’s like their whole lives are affected. And then you see people who are at 20% lung function and you say, how’s this person doing this with 20% lung function? So you have to say what is the main thing? And I will talk about those things, but think about this. If your patient walks in and they have Pullman and they have COPD or pulmonary fibrosis or pulmonary hypertension or asthma or anything else in the world, okay, if they’re 50 pounds overweight, I can tell you that they’re not being limited by their CLPD or the PF. They’re being limited by their weight. And that’s the main thing. Okay?



Just keep that in mind. Okay. So when I talk about things, I really, I’m going to tell you some things now that you can literally go back to your practice tomorrow and start talking about them with patients every time and get in the habit of doing how we communicate as a habit with people. So soon I’m gonna start talking to you as if you’re patients. Why? Because one thing I talked very plain English, okay? Sometimes I use French, and by that I mean pro-family, okay? But the idea is that patients need to be spoken to in a very simple way that they understand and educated in that way. Here’s the thing. If you have the attitude that you have a chronic progressive disease, that’s only going to get worse. There’s no cure. You’re going to get more and more short of breath and then you’re going to die.



Then you should not be talking to patients about education. You should not be educating patients because if there’s one thing that is the worst thing you can take from a patient, it’s hope. Okay? There are doctors that say to pay less. I talk to a lot of patients all day, every day online, 24 seven literally in the middle of the night talking to patients. Okay. And people say, my doctor said there’s nothing else they can do for me. Right? Anyone? I’m seeing the movie a lifeboat, Alfred Hitchcock. So this movie is about a cruise line or the crashes. It’s like the Titanic. And then there’s like 10 people in the boat and one by one they’re figuring out who to put out of the boat based on their characteristics. Now I started treating pulmonary fibrosis patients in 1995 when my mentor, dr ratio in ADA and I started seeing patients who were came in and they looked horrible.



Okay? The color was terrible. They were 90% if they’re lucky at rest, they would drop into the seventies as soon as they stood up and did anything. And these people were being excluded from programs left and right, but say you’re too sick for rehab, right? So if you are too sick for rehab, what does that tell you? Go home and die. Right? So our choice was this, go home and die or give it a shot. So that’s our choice. We really have nothing to lose. And then we started experimenting with oxygen. We said, you know what, let’s give these people as much oxygen as they need. Let’s give them $25 box and then if they need them, and you know, we started to see, we started to see over time that they really could do things and they actually got better and oxygen saturation got better both at rest and with exercise.



And there are programs that will say, you know what if your oxygen goes below 90 stop and wait until it’s done. Instead of saying no, turn your oxygen up as high as you need it. And you know, it’s like a thermostat, right? It’s like the best description I’ve heard of this is by doctor normal Braun, who’s like a medical giant here in New York city because she knows everything about everything. And she says, if the room is Chile, you put on your sweater and if it warms up again, you take your sweater off. Same thing with oxygen saturation. And a lot of times people will get this prescription. What’s the ticket? The oxygen prescription at rest. Everybody close your eyes and put up the number of fingers. Two liters at rest, four liters with exercise. Right. How many people are familiar with that at rest form four correlators of exercise.



And you’re the guy you said two years at rest. His exa. Did you test the patient in any way? No. Did you did you do a six minute walk? Which I hate the six minute walk. I’ll talk a little bit about why the six minute walk. Did you do any kind of testing? No. Why do you do it that way? That’s the way we always do it. And the patient’s like, Oh I cannot, I cannot raise it up. I cannot raise it up. Right? Why? Why a patient? Anyone at patients who are afraid of raising their oxygen too high. Why? Because it stops. You’ll stop breathing. Right? Did you ever hear anything so student, anyone ever heard that before? The weight. My doctor said if I turn it up to six, I’m going to stop breathing. Why have pops and drive theory? Anyone know what that is?



So it’s the idea that when you have this product leak, elevated level of CO2. Now where we don’t use CO2 anymore, well we don’t use pH anymore as our, as our stimulus to breathe, we now use hypoxic drive. And if you give the patient oxygen like a shark who doesn’t swim, that patient will die. I’ve been in doing what I do for 27 years. I’ve been an EMT for 18 years. I have never once seen a patient die or get into trouble by getting too much oxygen. I’ve seen a lot of people get in trouble by not having enough oxygen. Okay? So what I say to patients all the time, now remember what I’m about to tell you. I’ll give you a four word statement that you can say to your patients. Rely on your instruments, relying on instruments to tell you what you should or shouldn’t do.



Anyone scuba dive. Anyone fly plane before I have, I’ve done both. I don’t need to play now clinically. Anybody have this experience when you scuba dive, how do you know how deep you are? You haven’t done the gauge, right as a delegate because water is water and you can’t tell if you’re 50 feet deep or a hundred feet deep. So when you’re in the air, how do you tell how high you are? You have an altimeter. Why? Because air is air. You can’t help it 30,000 feet or 40,000 feet. How does a patient know what their oxygen saturation is? Right? There’s a lot of people will be, as I know, my oxygen saturation. I know it’s like the people at the carnival, they’re gonna be like, I can either guess your weight, your age, or your oxygen saturation. Right? There’s people who will swear that’s not part of the show that’s really outside.



So there’s, there’s people who say, I know my app and you don’t know, right? We all have patients. How many people have heard this question before? How could I be short of breath if my oxygen is 97% right? Yeah. We hear that all the time, right? When people say, well, you know, this patient who’s got pulmonary fibrosis, they’re 70% how are they walking around? Right? So if any of us in this room, if all of a sudden we cut off the air in the room and we were at 70% right, we’d be on the floor because our bodies aren’t used to it. But the point I’m making now is that we cannot use, we cannot have an arbitrary number for oxygen saturation and particularly when we’re dealing with the interstitial lung diseases, okay? Because these people plummet these people plumbing, okay? So that means that certainly the, the typical portable oxygen concentrator is not going to do the trick at all, okay?



These people need texts and very often the cannula is not going to do the trick and you need a mask. And I’ll talk more about that later, but think about it like this. How many people are seeing patients say, well, you know what I’m using, I’m I need six or four when I sit and do nothing. Then when I’m on the treadmill, I turned it up to 10. Sounds like a good plan, but what are you using on the treadmill? If you’re using a nasal cannula, then guess what? You are wasting that oxygen. You are not getting it. Okay? So it’s like I have this cup, it holds six ounces, but I pour a tenant. It’s a waste of time. So you have to be aware that there are things that we can do always. There’s always things we can do to improve it.



Never give up, okay? Because once you give up and once you have the idea that there’s nothing more I could do for you your patient’s going to sense that and they’re going to give up. Okay? I consider myself what I call a Malcolm X physical therapist, okay? It’s not a political statement. What I mean by that is that we will try to get our patients better, like any means necessary by hook or by cross. It means we have to give them oxygen. It means if two therapists have to stand with them while they’re on the treadmill, that’s what we’re going to do to get a better, and that’s why we get the results we did. Now I believe in this stuff so much, but I wrote a book about, okay, here’s something I’ve book as available to read for free online. Okay? I was given a gift by one of my patients.



A hundred thousand bucks said, I want you to make this book available for free, okay? And we did it. Okay, so any one of you and any one of your patients can go to poner wellness.com and read every chapter of the book for free. Now this is it right here. I could have, I could have done the whole lecture on one slide, but I know you would have been disappointed, right? What’s your my name? You have the same name as me. Noah brains back. Oh my God, I’m going to, I’m going to kill this guy. I got to hug this guy. I said, my man, see, he’s an old guy sitting there with a beard. That’s what Dr. Murray Berenson said to me. But I’ll tell you a funny story. I said, dr foyer is, this guy’s a medical giant. Let me tell you this. So we’re honored.



I’m honored to see you heckling by that. I am, I’m honored to have a heckler and I turn out, it’s, it’s dr foyer. Okay. This is, this guy is a real deal. Medical giant. Okay. So I really, I truly am. Am, am, I’m gonna give you new stuff, okay? Well, you know everything. So I’m not to read this, but check this out. I can do the whole thing on this slide right here, okay? This is what I consider the five most important things about living well with the respiratory and seat. Everybody wants to, everybody wants that silver bullet, right? They want that tincture that they could put behind their ears. They want the the essential oil. They want this, that, the other thing. And they want the cure, okay? Now I’m not saying you shouldn’t vote for those things, but guess what? The basics of what you need, okay?



The basics of what you need are right there in front of you and it’s medical. 18% exercise, nutrition, emotion, infection III is everything else. And this ranges from 10 to a hundred percent. Because guess what? You can do everything right, you step off the curb or I’m gonna break your ankle. All bets are off. But think about it like this and think about how people conduct medicine. Okay? Today it looks like this one, this one, this one, this one, and that one are all medical, right? And then like I said, on the way out, Hey, try to eat a little bit better. Hey, get some exercise, et cetera, et cetera, et cetera. A little bit as an afterthought. But the best thing a patient can do for themselves after they stopped smoking is exercise. So keep that in mind. This is ultimate pulmonary wellness. So when I talk about medical, okay, what I’m talking about is having the right doctor, having the right healthcare team, taking the right medications and taking them properly, okay?



That is very important. Okay. How many patients having the right doctor means having the right specialists? Okay. Having an internist who cares about you? I think every pulmonary patients should at a minimum, have a cardiac workup. Okay. From a cardiologist, again, very often when somebody has got a longterm respiratory disease, everything gets attributed to that disease. Here’s something a lot of people don’t think about. Okay. How many people? Well, I’m not gonna say how many feelings just going to tell you. Okay. A lot of times people get stress testing and the average stress test that people do is the Bruce protocol. Any people here do stress testing, exercise testing. So the Bruce protocol starts how you know the Bruce protocol for a stage.



Alright, sorry, sorry. Doctor for a, her a little bit. 1.7 miles per hour. 10% incline, right? So if you think about our average 85 year old patient with CLPD, they can’t walk at 1.7 miles per hour, 10% of the climb. And what winds up happening is one of two things. Either the test is positive, which is less often, okay. But what happens a lot of times is I’ll get something that said, patient walked for 47 seconds of the Bruce protocol, negative for ischemia. Right? Now, think about that. This is a diagnostic exercise test. But the patient was only able to tolerate 47 seconds. Why do you think that patient stopped the test?



You call me and that’s a big sob. So shortness of breath and or lower extremity fatigue before that patient has met any type of human dynamic end point. So heart rate may be a little high. Blood pressure may be a little high. Oxygen, maybe the same, but often I see almost no heart rate response. Almost no blood pressure response. They stopped the test way before that person would hit any type of anaerobic or ischemic threshold. And that test to me, you can rip out and throw away because it’s useless and it doesn’t give me any more competence in exercises patient than anything else because I know the patient didn’t get enough exercise. So keep that in mind. So this is medicine.






Most of what I know I learned from house, no, it sounds funny but it’s funny, but you can learn a lot from house. Okay. And the way that house gets his team to get to and they write every disease on the board and they’re crossing off. That’s a true differential diagnosis and people often don’t do a differential diagnosis. Okay? That is crucial. And even if you’re not a physician, if you’re an art teacher, if you’re a nurse, if you’re a PT, who else is in the room?






That’s it. Our team nurse PT, who’s an RT nurse, PT one heckler. So dr foyer is here. But the idea is that, you know what? The doctors often don’t have the time that we therapists have with the patient, right? And we can be their eyes and ears on the street and we can tell them things like, Hey, you know what? Your patient tells me that every time she walks up a Hill, she gets this kind of pressing pain in her shoulder blade, right? And you say, Hey, dr foyer, you know what? I don’t know if this is important or not, but I just want to let you know that this lady told me blah, blah, blah, blah, blah. Okay? That’s what’s called interdisciplinary multidisciplinary healthcare team. Not everybody operating in their own little world. Completely unaware. And as the therapist, you want to order the nurse or that you want to be nice for the patient, you want to make conversation with the patient, but you’re working, you’re doing a job, you have a role to play, right? And rather than say, boy, I am just the point, it’s rate of loss last night you could say, Hey, so how’s it going with that new inhaler you have? Right? And then when you avoid things like that,



He said they fix it. But it didn’t make any difference at all. Well, sometimes doctors make mistakes using her inhaler all the time a week when she showed me how to worse.



Alright, so that’s one problem, right? Inhaler technique, right? That lady’s not gonna get it.



Anything from her inhaler. But the thing is that even when people do things right, they often get married a little up. Okay? So you absolutely positively have to go over technique with your patients. Now when I see a patient for the first time, I’m going over all their medications with them. I’m watching them do their techniques. But here’s something that nobody ever thinks about. Okay? Anyone haven’t talked to their patients about what order they should take their PA, their inhalers and anybody. Dr. Ford. I know you can do everything, but that’s why you can heckle me unabashedly. So what order do you think patients should take?



No, on the table. I tell them that. Wait till, cause they also have aerosol [inaudible] open.



So you’re saying that, okay, so you’re saying nebulize before a pump, but doesn’t it depend on what medications in there? Huh? That’s right. So doesn’t it depend what medication they take? What? So, so anyone have a real idea about this that they do with that? Tell me sir. [inaudible] Okay, that’s a great technique. But what, what about short term and long term? What if, what if they take albuterol? What if they take pro air and Advair? Which one goes first? Why is it wrong? Isn’t accurate. Bronchodialator tail as a long acting [inaudible] let me throw an idea out to you right now. Okay. You know anyone watched a bill Maher? Bill Maher has a bitch that he does and he goes like this. He goes, I don’t have any proof. I just know it’s true. Okay, let me throw an idea out to you. And I’m not even saying that I’m right. Okay. But think about this. What kind of medication is albuterol? Satin short acting beta. Beta two agonists, right? What kind of medication is an app there?



Long acting. So we have a lab, right? I hate using those words. I need in the main right, but, but like we have a long acting beta two agonist and we have steroids right now. What? What does it mean that it’s a beta two agonist? Anyone know what’s up? Well access to but, but there’s long acting and shorting bit short acting beta two agonist, right? So what is the specific meaning of beta two? Agonist. Sympathetic nerve. So it’s beta an urgent, right? But it also acts on specific cells. Are we in agreement with that back and forth here? Very well. Okay. So what if all these seats right are the beta two receptor sites and all you got are short acting beta two agonists right now, what the hell happens when I open the door and I need my long acting beta two agonist to get into your system like the foyer, what?



The immediate effect of the short acting so that when you take a look, I think it gets into this self every quarter. That is one theory and I’m not anyone to argue with that, but I just, I can’t, I use swatting. Flies, flies, talking medicine. He’s swatting flies at the same time we’ve said let’s switch seats. No, but listen I that’s the, that’s the thinking, right? That’s the thinking is open up the airways with the short acting beta two agonists. But let me ask you a question and again, it’s something to think about. I’m not saying I’m definitely right. I’m saying think about it and try it with patients and I on any patient that I, that we’ve spoken about this with, with the permission of their physician. Okay. Because a lot of times, how many people say, which one did it take for? My doctor said it didn’t matter.



It doesn’t matter. Right? Anyone to ever hear that? So how many people think it doesn’t matter? Raise your hands. You’re not gonna raise here now because you assume I’m about right. But here’s the idea. Here’s the idea. But what if you fill up all your BAS? How many anybody say this? I don’t think this Advair does anything, right? I take this out it, I don’t think it does anything. Now think about this. And again, I’m not saying I’m right, okay? But here’s something to think about. If I take all the beta two agonists or the beta two binding sites and fill them with short acting beta two agonist, then maybe the long acting Bronco dilator doesn’t work as well. Maybe. Maybe. Okay. And if that’s the case, then guess what? The 12 hours you’re supposed to get out of Advair is not going to happen, right?



And they’re not going to feel a steroid, right? So with the, with the albuterol, you definitely, you take it, you feel it after maybe yes, maybe no. Okay. And the steroid, definitely not. Okay. The steroid, definitely not. So here’s what I think, and this is on the book. You can read it online for free. I’m not plugging. Okay. But this is what I think, if you can take the long acting, like a lot of people say, I get up in the morning, I can’t, I have to take my albuterol, I have to take my short acting meditation. Try just try to take your long acting medication first. Let that get in there and give the Pryor. It’s like I say to people like this, if you in a shopping spree to Walmart, don’t go to the go mile. Okay. And what I mean by that is put the big guns in first.



Prioritize your heavy hitters. So give them opportunity to take the long, I used to always wonder, and you know, this is something that I’ve been thinking about literally for years. And I’d say what’s an easy way to teach patients about medications? Because very often patients don’t know what you get and you go home, you have three prescriptions, you come home, you have an ed, a disc and a pump, and you don’t know the difference between me and them and you don’t know what they do. And it’s important for people to understand what they do because if they’re taking an anticholinergic and they’re taking a beta two agonist and they’re taking flow of it and they take the flow of at first, well that’s probably not going to be best for them. Right? So the idea is sounds like, how could I think about this? How could I, my mind works like a Rubik’s cube.



You probably probably are getting that. I don’t think like most people, I know you probably don’t believe that. But like it’s, it’s like looking for things, looking for ways to twist things into a way that’s organized. What can we do? What can we do, what can we do? And after like three years of thinking about this, I was like, Holy crap. Anticholinergic starts with it. They’ve got to ask. And that starts with B and corticosteroid starts. Let’s see, ABC. I was like, Wes, now check this out. Trilogy now has a commercial, right? G one, two, three. They don’t say ABC, they don’t say ABC, but I know they got that for me. Trilogy. I know they got it for me. Okay. But here’s the thing. When when I always wondered why they would put a beta two agonist with a steroid, it never made sense to me.



Okay. But in that case, okay, the steroid is the star of the show, right? Because the steroid is what’s is, what’s going to give you the longterm anti-ice, excuse me, longterm inflammation. So we didn’t have to make sure that that patient is getting that steroid, right? So in the case of let’s say a Spiriva and Advair, I would like the patient to take us for Riva first to open up, and then you get the second Bronco dilator. But the steroid is at least getting the chance. A lot of people wake up and say, you know what? I wake up in the morning. I can’t get a breath. Right. Instead of take the steroid when they’re all locked up. Makes no sense. The beautiful ones, and I’ve been waiting for this for a long time. Are these the neuro, the Ultibro? I mean nobody that I know it takes Ultibro Ultibron but the normal, the Aalto, right, because that makes perfect sense.



Anticholinergic beta two agonists. We know that the a and the B work best when they’re taken in close proximity to each other, right? So that’s a perfect combination. But then don’t shove dessert down your throat before you ate your meal. Right? So don’t take the noro and then shut that steroid down your throat immediately because nothing happens, right? Give it 15 minutes to start working. Take your steroid. Make sure you tell your patients, check this up. Rinse. How many, how many people heard this? How do you get a patient? Say I rinse my mouth out. I gargle, I brushed my teeth. I did. People say all different. Do they have to brush their teeth? I don’t know. But what I say to people, people listen specifically to what I’m saying right now. Rinse and spit, gargle and spit. Why do I say it that way?



Because if, if you only gargled in all the medicine that was in your mouth, you just took it into your throat, right? So rinse clear the mouth first, then spit it out, then garbled, then spit. I don’t know about that. Brushing the teeth thing, I don’t know if you have to do that, but I don’t know how much of that is the positive on your teeth really. But that’s the stuff I talked to patients about when it comes to their medicine the first time I see them and they say, you know what? No one’s ever told me this before. And I say, I know, except for the patients. Have one physician. Guess who it is, doctor.



No, but the idea, but the idea is that nobody talks to patients about this and it’s not the doctor’s fault. Okay? It’s not the doctor’s fault because they don’t always have time to do that, but take it upon ourselves as physical, respiratory, nursing, et cetera, et cetera. Anybody who comes into the life of the patient can talk about these things and can reinforce that message over and over again. There’s a great book. If you want to read a really brilliant book about patient care, this call tonight and a half things you, your hospital would do differently if Disney ran and ran your hospital. Okay? Believe it or not, Disney runs hospitality training courses through hospitals and healthcare. Why? Because it’s the happiest place on earth. They’ve taken satisfaction to an arc core. Right? And so what they say to you is how you say something to a patient makes a big difference in how they feel.



So nurse walks into the room, checks on the patient, everything looks okay, walks out, patient doesn’t even know they were there. Right? But if you’re going to go, hi, I had some extra time. I had, I had some extra time. I want it to come in. Is everything okay? Is there anything that patients think right? And that’s what makes the difference. Okay. The doc, you know what I do if I have to communicate with somebody, like I communicate a lot by email. I set my clock for 3:00 AM and that’s when I send all my emails because they my pay say, can you believe it? He’s up at 3:00 AM sending me an email. No, I’m just [inaudible].



But the idea is think about what you say. Okay, so there’s bad communication like a jerky. What are you doing here? What is still having no, that’s the obvious, right? Nobody does that. Okay. But then there is the fluff. The fluff is nice weather we’re having. How’s the wife? How’s the golf game? Mets are doing. Great. Well you’d never say it mentioned there. 10 minutes. Okay, I’m going to hurry up. Alright, here we go. Exercise frequency, intensity, time, duration, frequency, every day. Okay. You need to be doing some kind of exercise every day. Doesn’t have to be a rehab, doesn’t have to be in the gym, but sometime type of activity. Intensity, time, duration, intensity. Okay, this is very important. How intense should you be working?



How many people say 70% of max? 80% of max. 90% of math. 190% a hundred percent 50% check this out. It depends on the max. Okay. So you have to look at the tests that you’re doing because if you did the wrong test, if you’re doing the Bruce protocol and the patient stopped at 47 seconds, I mean if we give you, you know, 80% of that, it’s like sitting and drinking a peanut colada, right? So as long as the vital signs are okay, we will let you work out as hard as you can. Breathing retraining is important, personally. Breathing, diaphragmatic breathing, paced breathing, recovery from shortness of breath. Very, very important to teach people about recovery from shortness of breath because people are terrified. And if you don’t know how to swim, you’re not going to go in the ocean, right? So you don’t know if you’re going to walk to the grocery store and it’s going to be like, Oh no, it’s the big one.



You’re not going to the grocery store and all activity is going to go down. If secretions are a problem for a patient, this is very important. Just physical therapy, postural drainage, incentive spirometry. How many people recommend it to their patients? Now, many people recommend that at home for their patients. Okay. I don’t like it. Okay. I don’t think it does that much. Okay. In the hospital, absolutely. Post thoracic surgery. Yes. Post the dominal surgery. Yes. Bed bound. Yes. Inactive. Yes, but once your patient can get up and walk around, they’re taking greater tidal volumes and they’re going to get from an incentive spirometer. These things work. Positive. Excretory, pressure devices, flutter, acapella robot, the lung flute, quake. My favorite are Rebecca aroma. You want me some money? Next. Favorite acapella. Okay. Flooded. You have to give credit because it was the innovator. Okay. It was first without the flutter. You don’t have the Rebecca and the acapella, but these secretion clearance devices really work and daily prevention is crucial. Okay. We BFS breathing. Balance, flexibility, strength. That was a fast thing,



So we had to create a program that would support the respiratory system in the best way that we can. I hate to use the word think out of the box because everyone is using that word now. There’s an ultimate thing out of the box. You feel like your breath and panic has set in. These are the times when it’s most important to talk to yourself. Super, right, for pulmonary yourself that you know what to do and remind yourself that you have certain tricks that you can utilize. Astro, teach the patient you have recover showing us where you have to.



That’s my grandma. [inaudible] Yoga, awesome for patients, respiratory disease, [inaudible] superstar Donna Wilson, teaching exercise so that your body becomes more efficient, stronger and thinner and using oxygen and there’s a million different things you can do. Breathing exercises, balance exercises, flexibility, exercise, crazy training. [inaudible] Look at Mary’s hair and that’s the key right there. You have to get to the bottom of the patient’s life. And the thing I ask people all the time is, what are the things that make you uniquely who you are? And you have to find that in the patient and help them achieve that and find that fire again. Pulmonary cardio. I really, I thought they were right. I didn’t have enough time. Treadmill, bike. These things are all cardio, arms up. This is our online walk about, okay, so we have film that we shot all over the world. If patients are going to be exercising today, starting at four minutes on day one in 42 days, we get them up to 30 minutes.



I’m going to take it, take it up. Nutrition, very important. How many people talk to their patients about nutrition? How many people refer them to a nutritionist? The rest of you do nothing. What do the rest of you do? All right, so check this out. A lot of nutritionists, I’m sorry to say, no disrespect to nutritionist. I love nutritionists, but there’s very specific pulmonary nutrition that’s very different than regular nutrition. Okay. Does anybody know anything about pulmonary nutrition? What you go? Yes. Yes. Check this out. First of all, anybody here that’s, I went to the restaurant. No. After the restaurant I had to call a taxi to get home. Two blocks, right? Why? What’d you have to eat? Pasta, blah, blah, blah. Tiramisu, alcohol. There’s the mechanical aspect of eating a breathing, which is that your stomach is full and your stomach doesn’t care if it’s liquid, solid or gas.



Right? This is going to push up on the diaphragm. It’s going to increase the resistance on the diaphragm and make it more difficult to breathe with the chemical aspects of eating and breathing or this. Anybody aware of the respiratory quotient? Raise your hand. Okay. Respiratory quotion says that carbohydrate has a value of 1.0 and protein has a value of 0.8 and co and fat has a value of 0.7 when it comes to production of carbon dioxide. So what that means is that carbohydrate metabolism will cause the greatest amount of carbon dioxide production. And then what does that, what happens after you have that high carbohydrate meal is your brain says breathe, breathe, breathe, breathe. Great. Very, very, very good. So now you have this mechanical aspect of eating and breathing and then the chemical aspect of that. So for patients with respiratory disease, we advise them low carb or no carb, particularly for the patients that are trying to gain weight. Okay. As low carb as possible. High protein, high fat. Another thing about nutrition that’s really important. Protein and carbohydrate. How many calories per gram?



Screaming out? 4.4 okay. What about fat? Nine. So for the patient who can’t gain weight, right? Fat is their best friend, especially with the ILD patients. Okay. And what I noticed with ILD patients, I’ve never seen it, I’ve never seen it spoken about or written about. But this is what I noticed and people can do well and then there’s a certain point okay at which the breathing and the calorie, you know, utilization, they burning so much calories and that combination of increased metabolism and the inability to get enough food. And then I see people plumbing. Okay. I see. That’s really a bad side. So when I say keep the main thing, the main thing, what I mean is that if your patients cannot keep on weight every time you see them, they’ve lost more weight. That has to become super priority. And for the patient that says, well, you’re asking me to do more exercise well, that is going to make me burn more calories, the answer is no, it’s going to make you more efficient.



You’ll actually be burning less five minutes. Okay, got it. That’s me when I was in cooking school, stress, anxiety and depression management. Okay. This is basically emotional. Okay. I don’t like the idea of sad, but I would have had to go to second line. I would have to go to a second line and I’m all about aesthetics. So the idea about this is it’s very anxiety provoking when the number one symptom of your disease is shortness of breath, right? I mean, what’s more scary than not knowing if you’re going to be able to catch your breath. So how do we address that? Okay, we address by number one, teaching people more effective breathing techniques. Number two, teaching them how to recover from shortness of breath. They don’t know any positions for covering anyone. Raise your hand if you do. Okay. Check this out before anyone to see that patients doing this, they don’t want to see that patients who are in this, anyone see that patient sitting and doing this or doing this?



Why is this effective? Okay. A concept that I call open chain versus closed chain activity. This is open chain. When my arms are free to move around in space, this is open chain. And when my, when I’m in an open chain, the back muscles do things like this and this, my chest muscles do things like this and this, my shoulders do this. But when you close the chain right now, many people saying, why can’t I walk on the treadmill? But I can’t walk a half a block outside. When you close the chain, all of the muscles that I just spoke about work in their reverse activity because we’ve now fixed this to help elevate the rib cage. And so here’s something to think about that a lot of people don’t like it, okay? Because they feel like it’s a setback. But a lot of times as a training tool, I say to people, you need a rolling Walker. Okay? And the reason is you’ve fixed the upper extremities, they now get breathing benefit and they can walk more and then they may be able to put it down at a certain point. But there’s patients who say, I can’t walk a block or a half a block and I take them outside with a rolling Walker and they can,



You have to motivate your patients. Today, we’re going to have deep thoughts, motivations, and meditation. It might be a thought that I want you to think about and it might be an idea of saying of a poem that I want you to take into your day and figure out how that relates to you. I’m going to motivate you to get you moving. Right itself is always great and life is precious and life is something that is 20 years. The second best time is today. It’s never too late. Powerful. Okay. As I said before, I can be our best friend when it’s helping us. It can be our worst. There it is okay to not be strong all the time. It is okay to not be happy all the time. It was okay to be weak at times. We all have those moments because not honoring, honoring our the ones that have been the first one to be there with a friend who needs a friend and D often going to be the last person to ask. Remember and ask yourself, how much of this is real now? Much of this is what I’ve been conditioned to believe over time. It doesn’t matter where you are right this moment. This is our story.



And she said, well, maybe not as strong as you. She said it’s not a good thing, but it’s a real thing and you have that pride or you do it right out of Europe and I don’t care. And then you get back. Okay.



All right. So the idea is joined with your patients in this teamwork. Okay? There’s often a line if you’d say, well, we know what, we’re not going to go on the other side of that line with the patient, right? We need to keep this boundary up. Now look, I know why it’s there, but to me, treat the patient like a human being. Okay? When you’re like, I am all knowing I am all being. This is also super important. Handwash okay? How many people don’t go through the whole day? Go through the whole day. They don’t want to wash their hands ones. Okay, sounds gross. I know it happens. Okay, sounds gross. I know it happens. You go on the subway, you don’t know if typhoid Mary was just on the subway before you, and then you put that, here’s, here’s one way I got, had two trips in a row where I got sick both times on a plane.



I started bringing those antibacterial wipes. Sometimes they get black coming off the seat. People look at me like I’m crazy, but I never get sick. Now I to a flight attendant once I said, how often do you guys clean the seats? You know what she said? Clean the seats. That’s no joke. I mean, that’s no joke. We’re trying to turn around the plane fast, right? Keep that in mind. Avoid sick people. Right? That’s a hard thing to do because you have, Oh, but my grandkids are coming to town. But if all your grandkids have a cold and you have COPD or pulmonary fibrosis and you wind up in the ICU for a month because of it wasn’t really worth it, especially in the days of Skype and zoom and this and that and the other thing and FaceTime. And of course it’s no fun to hug an iPhone. Right? It’s just fun to look at it and let it lead you everywhere that you’re going in life. But masks, if you’re sick masks around sick people or if you know you’re going to come in contact with us to chemical flu shot pneumonia vaccine. This is kind of the culmination of ultimate pulmonary wellness after,



Okay, this is the medical component exercise.






I think we have to stop here. I usually take four hours for a talk. But keep in touch with me. Go to our website, sign up for our list. We’re going to have a course called pulmonary wellness. The blueprint, we have dozens of webinars. They’re free. Watch them ask questions. We have coupons, $50 off bootcamp for your patients. But if you want to learn, you guys can do boot your learning. Please fill out your thing. Please come back. I got my console up. Hang on. Please fill these out. Okay. And also one thing you should know they told me I was going to go over, okay. They were right, I was wrong. But here’s the thing, I also said I would give up all the money I’m getting today if I didn’t get at least 4.5 average.



If you liked it, you know. No, I’m just kidding. I will answer questions. I’ll be around. I hope you guys learned something, but there’s a lot. If you’ve learned one thing about this today, please engage with your patients. Okay? Make enough time for them. Check in on them. They’re people. Think about how you want to be treated. These things are obvious. There’s that over and over and over again, but they’re often ignored. Yes sir. I’m patient. Love you. Thank you. [inaudible] Yeah, yep, yep. Absolutely. That’s why we have it online. We need it. So let me talk about that for one second before the other guys come in. So, oxygen, okay. When you want something done on your home, everybody wants three things. They want it done fast. They want it done good. They want it done cheap. You can have any two out of the three.



When it comes to oxygen, everybody wants three things. They want a tank that’s lightweight. They want a tank that lasts a long time and gives you a lot of oxygen. Okay, you can have any two out of the three. So the answer is no. Okay. Currently the portable oxygen concentrator maximum is three liters per minute. And another big thing if go online, I just did four articles and a two hour webinar on oxygen. It’s called oxygen manifesto. And the thing is that everybody walks around with these energies, sorry, in a gym. But it’s true. And they think they’re getting six liters per minute. No, they’re not. Okay. So look at that. There’s another great resource for you. It’s called the pulmonary paper portable oxygen concentrator review guide. That’s something you need to know about as an artist. But keep in touch. Go and follow us on Instagram, Facebook. Join the Facebook group and you will learn and you will engage with more patients than you have time for. Have a great day, everybody. Thank you for your attention. Thank you. Yeah.