1/7 Spacers confused me, so I wanted to sort them out. Let’s start with a question - what type of inhalers can benefit from a spacer?

#MedTwitter #FOAMed #MedEd #MedStudentTwitter #PulmTwitter
2/7 Metered dose inhaler (MDIs) are best used with a spacer! Pressurized devices were invented far earlier, but the technology was adapted to treat asthma in the form of an MDI in 1957 by Riker Labs. smithsonianmag.com/innovation/his…
3/7 MDIs have various advantages and disadvantages, some of which can be mitigated by spacers.
rc.rcjournal.com/content/50/9/1…
4/7 Here is a fantastic review about spacers, including an overview and considerations of different spacer characteristics. ow.ly/EDs730keDOw basicmedicalkey.com/paedeatric-and-geriatric-formulations/
5/7 The CDC has a nice fact sheet about proper spacer use. Given how many steps there are, it’s not surprising that they are not used with perfect technique!
cdc.gov/asthma/pdfs/In…
6/7 An article from CHEST in 1989 even suggests that MDIs might be as effective as nebulizers (specifically in sympathomimetics)!
doi.org/10.1378/chest.…
7/7 In summary:
1️⃣ MDIs are the only type of inhaler that require a spacer
2️⃣ Spacers can be beneficial if used with proper technique
3️⃣ Proper technique is very difficult to execute

Please share any thoughts!

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More from @SatyaPatelMD

9 Jul
1/7 Let’s go over the evidence-based physical exam for lower extremity deep vein thrombosis (LE DVT). In the spirit of quantifying clinical concern, here is a question - besides inspection (and #POCUS), which tool will help you the most?

#MedTwitter #FOAMed #MedEd
2/7 The answer is a ruler! Let’s look at the LRs.

Quick review of LRs:
- The (+) and (-) indicate the LR if a finding is present or absent, respectively
- The more the LR deviates from 1, the more useful it is
3/7 For this particular set of exam findings, it may be more helpful to see how much the LRs change your post-test probability (assuming a pre-test probability of 50%). The presence of absence of asymmetric calf swelling seems to be the most helpful.

Graphic from McGee
Read 7 tweets
7 Jul
1/4
Let's review the evidence-based physical exam for Cushing syndrome!

Quick review of LRs:
- The (+) and (-) indicate the LR if a finding is present or absent, respectively
- The more the LR deviates from 1, the more useful it is

#MedTwitter #MedEd #EndoTwitter #FOAMed Image
2/4
Things that stand out to me
- "Buffalo hump" doesn't have a defined LRs despite being taught as a "classic" finding (occurs in 34-75% of patients)
- The presence of moon facies has a lower LR than I expected (1.6)
3/4
- The absence (or presence) of abdominal striae is not particularly helpful
- The presence of a thin skinfold (thickness on the back of the hand <1.8 mm in women of reproductive age) can be VERY telling
Read 4 tweets
23 May
1/ Had some fun today on rounds with these! The Rinne and Weber tests stress out a lot of folks, so let's tackle them today.

#MedTwitter #MedEd #EndNeurophobia @MedTweetorials
2/ What are the Weber and Rinne tests used to help identify?
3/ The answer is both! Remember that the most useful exams are hypothesis-driven so you need to do a history to begin suspecting if a patient has either type of hearing loss. This will help you generate a pre-test probability for disease (this will become relevant later).
Read 13 tweets
14 May
1/8 When might an FeUrea not be as useful as FeNa? Let's explore briefly!

#NephTwitter #MedEd #MedTwitter #Tweetorial #FOAMEd @MedTweetorials
2/8 First of all, a quick reminder that the utility of the FeNa and FeUrea in evaluation of AKI needs to be carefully considered before they are ordered (I'm a big fan of looking at UAs). journalofhospitalmedicine.com/jhospmed/artic…
3/8 You might see a table like the one below that can be used to (cautiously) interpret FENa and FEUrea.
Read 8 tweets
22 Mar
1/11 Congrats to those who matched! I tweeted about an inpatient pocket card set in 2020 and got great feedback. Here is the result of a big overhaul: bit.ly/pocketcardset

Let's review what's inside!

#MatchDay2021 #MedStudentTwitter #MedTwitter #TipsForNewDocs #FOAMed
3/11 First up is a pre-rounding checklist. Be systematic and read all of the notes in your patient’s chart (interdisciplinary care is critical).

H/t @nickmmark for the idea to use a QR code to maintain an updated version! This QR code also has some additional resources. Image
Read 11 tweets
23 Jun 20
1/14 I was always asked as a student if I wanted to give fluids to a patient, but no one ever told me how they think about. Here is my approach to giving IV fluids.

Disclaimer: Things are simplified for the sake of pragmatism.

#MedTwitter #MedEd
2/14 I call my approach an "IV fluid timeout." It involves asking yourself four questions before giving someone IV fluids.
3/14 I broke down the answer two question one into two major buckets. This is the most important question because if a patient does not need IV fluids, do not give IV fluids.
Read 15 tweets

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