It seemed as if the switch from CFC inhalers to HFA inhalers would go off without a hitch.

Manufacturers increased production to prevent shortages, and the American Lung Association even produced a public service announcement announcing the change.

But now, a backlash is forming. A small group of people with asthma is raising a commotion online - saying that the new inhalers don't work as well and, because most HFA inhalers don't have dose-counters, the devices could threaten their lives during an asthma attack.

The group started an online petition, fueled by blogs and forums. More than 2,000 people have signed it, complete with comments raging against the change. (Some signatories chose to have their names remain private.)

Their complaints range from the higher cost, to the bad taste, to allegations that the new inhalers don't work or even make symptoms worse.

Even consumer affairs websites are getting in on the act: this one chronicles several episodes where the inhaler made the person with asthma feel worse.

Patients are slowly learning that at least some inhalers contain ethanol and can worsen an attack. (PDF).

For tips on helping your patients adjust, visit the AAAAI article on transitioning to HFA inhalers. A patient assistance program from the partnership for prescription assistance could help defray the costs.

Combating an industry that has spent decades building an image that smoking is cool, New York City is airing gruesome images of suffering and disfigurement on television and in subways and taxis.

New York City's Department of Health and Mental Hygiene has launched a series of commercials profiling a Bronx woman - Marie - who has had nearly 20 amputations. The ads coincide with the city's nicotine-patch giveaway, happening through May 1.

Marie developed Buerger's disease after smoking for 12 years. Buerger's disease, also known as thromboangiitis obliterans, is characterized by a narrowing or blockage of the veins and arteries of the extremities, reducing blood flow to these areas. The first symptom patients often experience is extreme pain in the lower arms and legs while they are at rest. Buerger's disease occurs in 6 out of 10,000 people, mostly in young or middle-aged males with a history of smoking or chewing tobacco.

image: New York City Department of Health and Mental Hygiene

She can't hang pictures or screw on a lightbulb because she has no fingertips.

"Everything I do now I have to stop and think, because just me banging my hand or something could cause me to lose my fingers," she said in the commercial. "That's not living."

The commercials show close-up images of the saw bone, clippers, and medical equipment used in her amputations. Marie holds up her severed fingertips to the camera.

The Health Department learned about Marie through a telephone survey of smokers. After hearing her story, the surveyor asked if she would be interested in sharing her story, according to Jennifer 8. Lee of The New York Times. 

As a result of her amputations, her friends didn't want to call her, she said. Her kids became embarrassed of her appearance. Her companion of 10 years left her. "He couldn't take it anymore," she said.

Marie was able to quit smoking in 2006, according to The Times. She used the nicotine patch.

Rhythmic jazz music and the sweet scent of flowers filled the Philadelphia Convention center during my last visit for the Philadelphia Flower Show. This time, the sniffling was the same-blame it on Philadelphia's late winter weather-but  the topic, pediatric asthma, generated more serious dialogue.

Health care professionals gathered in the ballroom for the public airing of the EAACI and the AAAAI's PRACTALL Diagnosis and Treatment of Pediatric Asthma. The document discusses diagnosis through spirometry, exercise challenges, and questions tailored to age groups. It also addresses treatment considerations such as airborne allergen avoidance, pharmacotherapy, and educational programs. The session drew crowds of health professionals curious about the document released just eight weeks ago.

Among those inquiring about allergy avoidance and drug side effects, one woman voiced a question that seemed to be on everybody's lips.

How do we balance these new guidelines with GINA and U.S. guidelines, asked Nancy from San Diego, Calif.

"Guidelines are guidelines, they were never intended to be a straight jacket," said session moderator Anthony J. Frew, MD, FAAAAI, Department of Respiratory Medicine, Brighton General Hospital, United Kingdom.

In an interview following the session, Leonard B. Bacharier, MD, FAAAAI, Department of Pediatrics, Washington University, St Louis, MO put it a little differently.

These are not intended to serve as guidelines, said Dr. Bacharier, but rather a consensus document.  As with all elements of medicine, consensus does not always mean unanimity, he added.

Diagnosis and treatment vary greatly between countries and even doctors, Ulrich Wahn, MD, PRACTALL chairman and head of the Department of Paediatric Pneumology and Immunology, at Charité-Humboldt University, Berlin, Germany, had said during the session. The same patient might be prescribed immunotherapy in Germany, sublingual immunotherapy in Paris, receive no diagnosis in London and be treated with leukotriene receptors in the United States, he said.

This document reflects those differences, said Dr. Bacharier, and points thoughtful clinicians down a road of further inspection and research.

Kirk Walters of The Toledo Blade

Can I throw recyclable products in the trash guilt-free? Do I feel comfortable eating meat from a cloned animal? What exactly will happen to surplus embryos from in vitro fertilization?

Lord Robert Winston gave conference attendees several points to ponder about this last question during his keynote address about forgotten risks in the stem cell debate on Saturday. The British government and public generally have accepted stem cell research much more readily than the U.S. had, said the professor from the Imperial College in London. For many of our friends across the pond, it's a fairly simple ethical issue - it is far better to potentially save lives than to waste embryos.

However, the stem cell debate has been far from clear-cut in the States. The scientific and religious community have warred over the issue, and the government even weighed in when President George W. Bush vetoed an embryonic stem cell research bill, saying it crossed a moral boundary. Lord Winston suggested that the government's disapproval could warrant more harm than good.

While experimentation with stem cells has seen some amazing successes, embryonic stem cell research also entails some massive problems that have not been solved. He stressed that this fragile field needs some sort of regulation or scrutiny. Lack of government approval also pushes stem cell research into the private sector, whose research results are not often met with confidence from the public.

Lord Winston emphasized that more open engagement between the scientific/health care community and the general public is a crucial part of the solution to addressing this distrust. Science is not black and white, it's uncertain, he said. He urged attendees to beware of certainty about new scientific discoveries and to remember nearly every new scientific achievement exaggerates its true value and carries along with it a forgotten risk.

If scientists more openly communicate these risks and in turn listen to the public's fears and concerns, we may be able to bridge some of the gap between science and the masses through more honest dialogue. Such a relationship would provide a more productive forum to discuss new scientific and technological advances and help move them forward.

When Jennifer Moyer Darr, LCSW, a social worker with the National Jewish Medical and Research Center, Denver, Colo., asked one of her young clients suffering asthma to draw her illness, Darr was puzzled by the crayon markings on the page.

A clown named Azma filled half the page, flashing his fangs and wearing a pink flower in his fedora hat. The girl drew herself less than half the size of Azma, standing in the corner of the page, and lobbing "Mega Pills" at the monstrous clown. Large words were scrawled across the top of the page in red crayon: Killing It!

"It" refers to the 1966 sci-fi movie of the same name, Darr later realized. Most striking about this drawing, the child felt she had to battle her disease alone with her "Mega Pills," Darr said.

By contrast, another child drew his asthma as a blob in the corner of the page. He and his family stood smiling under a large umbrella - held by an adult. This child felt his family offered a protective barrier against the disease.

Speaking this week at the American Academy of Allergy, Asthma, and Immunology annual meeting in Philadelphia, Darr said she learns more about how her young clients view their chronic illnesses from drawing than any other technique.

She and fellow speaker Melissa Korenblat-Hanin, ACSW, LCSW, addressed the psychosocial impact of asthma. Children and family members' attitudes about asthma fuel their daily thoughts and feelings, which can control their behaviors, said the presenters.

Typical issues children face include poor symptom perception, compliance issues, mistrust of health care workers, anger and resentment, trauma, and feeling like outsiders, among other problems.

Practitioners should assess how family members are dealing with a child's asthma, according to the presenters, as parents' attitudes and coping skills influence the child. One child wrote at the bottom of a picture: "Once upon a time I was nervous because my mom was nervous."

Families may encounter discipline problems. ("I can't tell if he's acting up because of his behavior or the steroids.") They also may struggle with independence versus coddling, neglect other family members or household responsibilities, and disagree with the other parent about interventions.

The presenters recommended saying to families: "We know managing a chronic illness is stressful. We have resources and people to talk with."

And while you're talking with families, the presenters said, give the child crayons - you'll learn more than you expected.

Roughly 7,000 physicians and health care practitioners are gathering in Philadelphia for the American Academy of Allergy, Asthma & Immunology annual conference (March 14 to 18). ADVANCE staffers will share highlights throughout the four-day convention in the interactive Respiratory Quotient blog community. Join us for discussions about lectures, keynote speakers, poster sessions, workshops, and seminars.

Are you attending the convention? Too busy to take off work? Looking for a great restaurant to have dinner? Does your hotel have bedbugs? Share your experiences and insights with the respiratory care community by filling in the "Leave a Comment" form at the bottom of each blog entry or contacting ADVANCE's web editor, Lauren Meade at lmeade@merion.com.

Daily reports from the campaign trail detail the health care proposals touted by our nation's presidential candidates. But while the contenders quibble about how to make health care more affordable and accessible in this country, governments across the pond have taken action to help reduce health care costs.

Just last year, Wales announced a somewhat controversial plan to provide free prescriptions to nearly 3 million Welsh pharmacy customers, regardless of their income.

Supporters have said the plan will increase access to therapies that treat chronic conditions such as asthma, thereby reducing the cost of preventable hospital visits. Detractors contend that the plan could dramatically increase the country's medical budget and lead to wasted medication.

Other areas have begun investigating similar proposals. Scotland plans to implement a free prescription plan by 2011 and will lower drug costs in the meantime. Meanwhile, charity group Asthma UK is lobbying Northern Ireland and England governments  to provide prescriptions free of charge to people with asthma.

A recent study revealed that drug costs prevented about 800,000 families from properly taking their medication, according to a Feb. 27 Asthma UK news release.

This "means many poorer people with chronic health problems are not getting the treatment they need and are putting their health at risk." Said an umbrella charity organization Citizens Advice Bureau, which commissioned the study.

Is cost the whole picture in asthma management? No.

Research has uncovered many other factors in the disease. Genetics, obesity, and environmental factors all play a role. The evolving profession of asthma education has also increased the understanding of the role patients' cultural backgrounds play in asthma management plans.

And in December, a study revealed a rather telling picture of the patients' role, concluding that patients with asthma would prefer taking fewer medications than having total symptom control. (The study did not consider whether cost played a role in this choice.)

Clearly, more research is need to understand the complex issue of asthma management. However, while political candidates debate the merits of any health care change, it might be worthwhile to ask you, the health care workers, what changes will make a difference.

Click here to see where the candidates stand on key health care issues.

If you're having trouble persuading your patients to quit smoking, you may want to warn them that the carcinogenic chemicals in cigarette smoke might slowly be killing their Nintendo Wii.

Nintendo says the residues in cigarette smoke can build up inside the Wii console. The residues fog up the lens inside the disc drive, preventing it from reading some game discs. The $250 game system has a particularly hard time reading the Super Smash Bros. Brawl game.

TechRadar.com is reporting that Nintendo has offered to clean the smoky consoles for free.

Tell us what you think: Should Nintendo encourage smokers to quit lighting up?

In the U.K., the British Health Service can deny operations for smokers unless they give up cigarettes at least four weeks prior to the procedure. The ruling applies to routine operations, such as hip replacements and heart surgery for conditions that are not immediately life-threatening. If smokers refuse to quit, they still have a chance at treatment but they'll have to wait longer.

A few highly-publicized cases have made their rounds on the blog circuit, narrating the tales of patients from Australia and the U.K. who have been refused elective surgeries unless they quit smoking. One example involves a National Health Service hospital in England that refused to operate on a 57-year-old man, who had broken his ankle in three places. They said his heavy smoking would hinder the healing process and increase the risk of complications, and refused to operate unless he quit. The man made several attempts to quit with no success and said he even cut down to just two cigarettes a day, but the hospital wanted all or nothing. Alternatively, doctors prescribed him morphine for pain management - a somewhat ironic response to the man's refusal to give up an addictive substance.     

While many hospitals and administrators feel this is a purely sensible, clinical decision to cut costs and improve patient outcomes, others feel it's an outrageous violation of personal freedom - some have even deemed it "torturous and cruel."

No one can deny the immense benefits of quitting smoking, but is it fair for the health care industry to make this decision for a smoking patient while so many other patients indulging in unhealthy practices slip under the radar?

In the wake of the glam and glitter of the Screen Actors Guild Awards, here's one more film to put on your list of "must sees."

Tobacco use is the leading cause of preventable death in the U.S., but studies have shown physicians don't feel equipped to counsel patients to stop smoking. Surveys of U.S. medical schools revealed most medical schools don't require clinical training in smoking intervention techniques.

A nine-minute educational film "Tobacco Ties" is aimed at filling that gap. Gail Marion, PA, PhD, associate professor in the department of family and community medicine at Wake Forest University Baptist Medical Center, is the screenwriter and producer. The film is part of the medical center's comprehensive program to train medical students to improve their tobacco intervention counseling skills.

It tells the story of a working mother who was raised in a family of smokers. Now, her cigarette addiction is aggravating her asthma, and she asks her physician for advice.

OK, so it isn't high drama, but it gets the point across. Respiratory care providers are in a prime position to motivate patients to stop smoking, help them set a specific quit date, initiate pharmacotherapy, and schedule follow-up visits.

You won't end up with a coveted statuette, but you could save a life.