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Friday, July 13, 2012

COPD: Is EMS Killing Patients with Oxygen? (1)

So this was one of the first bits of medical "lore" I learned as a spanking-new EMT-B. ("Lore" meaning things that are not found in textbooks, but that everyone knows are true.) You don't give oxygen by NRB to a COPD patient.
And you always leave a note. (Hurry up Netflix!)
Well, it turns out a lot of things I learned at that time have been discarded; MAST pants, the EOA, the long spine board (soon, soon...). How has high-flow oxygen fared?

Are we killing patients?
A recent study suggests that the old-time myth was true. In fact, if this study is corroborated, we may need to change our practice somewhat. The one-sentence summary of Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial is:
For high flow oxygen treatment in patients with confirmed chronic obstructive pulmonary disease in the prehospital setting, the number needed to harm was 14; that is, for every 14 patients who are given high flow oxygen, one will die.
That's a really high number.

By comparison, when we rush a STEMI patient to the cath lab, or give then thrombolytics, we have to treat 50 patients to save one life. This study suggests that we can save far more lives by using a nasal cannula instead of a face mask. Can this be true?

Let's first take a look at some older evidence, giving us some context. In the following post we'll go over the new article that has generated so much interest, and see if some practical conclusions can be drawn.

Two ICU studies
The authors of Influence of inspired oxygen concentration on deadspace, respiratory drive, and PaCO2 in intubated patients with chronic obstructive pulmonary disease wanted to study this (possible) myth of the hypoxic drive. They studied the effect of increasing oxygen delivery to a very sick bunch of COPD-ers, 12 patients who had already been intubated after a bad COPD episode. These patients were just starting to recover, being weaned from the vent, able to breathe or their own, and were likely to be extubated in the next day or so. 

The researchers bumped up the oxygen level to 70% for 20 minutes, and checked what happened with the vent and the blood gas. Although 70% doesn't seem high, it is actually right about what we are delivering with a standard non-rebreather mask at 15 lpm (See Weingart's article for explanation; PDF if you prefer).

So what happened? Apnea? Bradypnea? Failure of the hypoxic drive????



They, uh, got more oxygen. That's it. In this population of sick-sick-sick patients, nothing happened.


Okay, you say, perhaps they were a delicate population, but they had been getting beta-agonists and steroids, and probably antibiotics for a few days. That's the whole reason, after all, that they were being weaned off the vent - they were now better. 

Maybe we should instead look at patients who are not yet intubated, but might be if just one more thing tips them over.

"Our study included one patient - this guy"
So, back to the ICU. The authors of Oxygen therapy for hypercapnic patients with chronic obstructive pulmonary disease and acute respiratory failure: a randomized, controlled pilot study. looked at patients right on the brink, with PaCO2 > 50 mmHg, and PaO2 < 50 mmHG - members of the 50/50 club! They were not yet intubated, but it could go either way.


The investigators titrated oxygen up with Venturi masks to two different levels, either a PaO2 of > 50 mm Hg in 17 patients, and > 70 mm Hg in another 17 patients. They got all all the usual meds, of course. As expected, some of these very sick patients had to be intubated, and some even died. The rates of intubation and death, however, were the same in each group. And no CO2 retention either!


So why all the fuss? As an editorial in Critical Care Medicine pointed out, the main evidence for the harm of oxygen in COPD exacerbations comes from the 70s, a time before noninvasive ventilation, routine steroid use for COPD, and even Atrovent was barely a year old! Another editorial from the same journal lays into the medical-education complex for perpetuating this lore:
"One sample of medical mythology is the commonly told story that the administration of oxygen to a patient with chronic obstructive lung disease will shut down the patient's hypoxic respiratory drive and lead to apnea, cardiorespiratory arrest, and the subsequent death of the patient. ... It is not clear where this fallacious information comes from, but it seems to enter the medical information database at an early age, at the medical student or resident level, almost like a computer virus corrupting the appropriate function of the equipment. In addition, this myth becomes very difficult to extinguish during the career of the physician, even with clear factual information of long standing. The danger here is that this medical mythology will inappropriately influence treatment decisions in patients."
The Bottom Line
This is hardly a comprehensive review of all the literature out there on the topic, but most of the other studies are observational, and it's really hard to draw firm conclusions from that sort of data. I haven't bothered to review them here, because why waste our tine if higher-quality studies have been done?

With this background, I'll discuss the important EMS study from 2010 in the next post.

55 comments:

  1. So you've taken away our MAST trousers, our long spine boards, and now you're taking away our non-rebreathers...next you're going to tell me lights and sirens don't save lives!

    ReplyDelete
    Replies
    1. The problem with studying lights & sirens is that they're awesome. It's hard to deal with that confounding factor.

      Delete
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  2. Another myth busted? That was one of the first teachings when it comes to expiration physiology

    ReplyDelete
  3. Replies
    1. You know, I wouldn't say myth busted, so much as likely misplaced.

      There does appear to be some role with the higher FiO2 promoting V/Q mismatch, but the clinical evidence doesn't seem to demonstrate this.

      It's frustrating that so much of the evidence that suggests harm with hyperoxia is chart review, case control, and the like. It's very hard to sort out the associations, causation, and confounding factors, even in the randomized controlled trial I'll go over in the next post.

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  4. I'm a big fan of this post and topic, so I'll indulge in a case (modified, of course).

    I'll always remember the patient with a COPD exacerbation who came in with a sat of 90% on a NRB and refused most other treatment in the department. She wouldn't be intubated and couldn't tolerate NIV, so she ended up admitted, still wearing a NRB.

    When they called the code blue on her floor a couple of hours later I already knew who it had to be, but having perused a lot of the literature on the topic over my 4 years in medicine, I'm still torn as to how the events unfolded:

    Did hypoxic drive play a role? Probably not.
    Is there another mechanism at play that increases the mortality of these patients in the presence of high FiO2? Umm maybe.
    Did we kill her with a NRB? Probably not, she was already pretty sick.
    Did we expedite her decompensation with the NRB? Maybe a little.
    Should she have been coached and medicated more aggressively to improve tolerance of the NIV? Almost certainly, and in hindsight, I think that would have been the real game changer in this case.

    Still, it's so hard to force the human mind to disconnect correlation from causation. Yes, the patient had bad COPD, recieved high-flow O2 for a prolonged period of time, and ended up coding while still wearing the NRB, but that doesn't mean that the oxygen killed her. Maybe it was just the natural course of her disease, or maybe extended use of high-flow O2 is just a marker of less than ideal care. I'm certain we don't have the answer at the moment, but someday we will, and until then, I'll be keeping an eye open for new lit.

    ReplyDelete
    Replies
    1. I kind of like my analogy with acute CHF and fluid restriction I used in the post. If you conducted a trial (in EMS!) of fluid restriction versus "high-flow" IV fluids, but nitro and BiPAP were not permitted, fluid restriction would likely prove superior.

      However, if you allowed those same patients to get NIV and NTG, it probably wouldn't matter how much fluid they got, since it would be redistributed properly.

      In the same way, the high-flow oxygen can cause some V/Q mismatch, and produce higher alveolar CO2 levels that, owing to insufficient ventilation, cannot be expired, and so the PaCO2 can rise. BUT if NIV is employed, all that alveolar CO2 can be eliminated - no harm, no foul.

      Delete
  5. Bradypnea is a condition characterized by abnormally slow breathing or respiratory rates thus reduced delivery of oxygen to the body’s cells. Read more at https://healthjunta.com/bradypnea/

    ReplyDelete
  6. This comment has been removed by the author.

    ReplyDelete
  7. I did not know that smoking and copd are inter related. I just thought that drinking less water might be related with having COPD disease. Though that is misconception. This article is really amazing.There is also test & copd treatment available which is effective and less expensive too.

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    ReplyDelete
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    ReplyDelete
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    ReplyDelete
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    ReplyDelete
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    ReplyDelete
  21. I'm 59 years old and female. I was diagnosed a couple of years ago with COPD and I was beyond scared! My lung function test indicated 49% capacity. After having had flu a year ago, the shortness of breath, coughing and chest pains continued even after being treated with antibiotics. I've been smoking two packs a day for 36 years. Being born without a sternum caused my ribs to be curled in just one inch away from my spine, resulting to underdeveloped lungs. At age 34 I had surgery and it was fixed. Unfortunately my smoking just caused more damage to my already under developed lungs. The problem was having is that I enjoy smoking and don't want to give up! Have tried twice before and nearly went crazy and don't want to go through that again. I saw the fear in my husband and children's eyes when I told them about my condition then they start to find solution on their own to help my condition.I am an 59 now who was diagnose COPD emphysema which I know was from my years of smoking. I started smoking in school when smoking was socially acceptable. I remember when smoking was permitted in hospitals. It was not known then how dangerous cigarettes were for us, and it seemed everybody smoked but i was able to get rid of my COPD lung condition through the help of  Dr Akhigbe   total cure herbal medicine. my husband saw his testimony on the internet he used his powerful medicine to cured differents diseases. we contacted his email   [drrealakhigbe@gmail.com}   He has the right herbal formula to help you get rid and repair any lung conditions and others diseases, will cure you totally and permanently with his natural organic herbs,We received the medicine through courier delivery service. I wish anybody who starts smoking at a young age would realize what will eventually happen to their bodies if they continue that vile habit throughout their life.
    Dr Akhighe also cured diseases like, HERPES, DIABETES, HIV/AIDS, COPD, CANCER,ASTHMA,STROKE,LUPUS,JOINT PAIN,CHRONIC DISEASES,PARKINSON DISEASES,TUBERCULOSIS,HIGH BLOOD PRESSURE,BREAST INFECTION,WOMEN SEXUAL PROBLEM, ERYSIPELAS,STAPHYLOCOCCUS,HERPATITIS A/B, QUICK EJACULATION,GONORRHEA,SYPHILIS,WAST/BACK PAIN,PELVIC INFLAMATORY, DICK ENLARGEMENT,HEART DISEASES,TERMINAL ILLNESS,SHIFT IN FUCUS,ATAXIA,COMMON COLD,CROHN'S DISEASES,ALCOHOL SPECTRUM DISORDER,GRAVES DISEASE,HEARING LOSS, INTERSTITIA CYSTITIS,LEUKEMIA,MULTIPLE SCLEROSIS,OBESITY,RABIS,SCOLIOSIS,INFLUENZA, POLIO,JACOB,ETC. If you are out there looking for your cure please  contact  dr Akhigbe  by his email    drrealakhigbe@gmail.com     or contact his whatsapp number   +2349010754824
    God bless you Dr Akhigbe for your good hand work on my life

    ReplyDelete
  22. For the past few years I have had difficulty working out in yard, then in 2017 it got harder and harder to breathe. After many tests, it was a CT scan that showed COPD, emphysema and scarring in my lungs. I quit smoking 8 years ago but the damage has been done. I got to a point I couldn't catch my breath and was coughing so hard I thought the top of my head would blow off, nothing was really working to help my condition. Finally i came across Herbal Rich Herbal Gardens (ww w. richherbalgardens. c om) December 2018 and learnt about their successful herbal therapy for COPD. I immediately started on the COPD treatment; few weeks into the treatment, i began to notice a reduction in symptoms till it all vanished. I feel better and breath better. I Just wanted to share for people suffering from this horrible lungs disease.

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  23. Medical scientists have discovered a new way to battle HIV/AIDS and MENTAL DISORDER by using a man called Dr.Usifoh MY NAME IS VIVIAN MULLAN.I SAW A COMMENT ON POSITIVE BLOGS AND I WILL LOVE TO TELL EVERY BODY HOW MY STATUS CHANGES TO NEGATIVE, AND AM NOW A LIVING WITNESS OF IT AND I THINK ITS A SHAME ON ME IF I DON'T SHARE THIS LOVELY STORY WITH OTHER PEOPLE INFECTED WITH THIS DEADLY VIRUS. HIV HAS BEEN ONGOING IN MY FAMILY, I LOST BOTH PARENTS TO HIV. AND IT IS SO MUCH PAIN I'VE NOT BEEN ABLE TO GET OVER.. AS WE ALL KNOW MEDICALLY THERE IS NO SOLUTION TO IT..AND MEDICATION IS VERY EXPENSIVE..SO SOMEONE INTRODUCED ME TO A HERBAL PRACTITIONER IN AFRICA.. I HAD A JOB THERE TO EXECUTE SO I TOOK TIME TO CHECK OUT ON HIM.I SHOWED HIM ALL MY TESTS AND RESULTS.. I WAS ALREADY DISORGANIZED WITH HIV AND IT WAS ALREADY TAKING ITS TOWL ON ME.. I HAD SPENT THOUSANDS OF DOLLARS SO I DECIDED TO TRY HIM OUT ALTHOUGH I DID'NT BELIEVE IN IT, I WAS JUST TRYING IT OUT OF FRUSTRATION? AND AFTER 2 DAYS, HE TOLD ME TO GO FOR A NEW TEST. AND YOU WON'T BELIEVE THAT 5 DIFFERENT DOCTORS CONFIRMED IT THAT AM NEGATIVE..IT WAS LIKE A DREAM,,I NEVER BELIEVE AIDS HAS CURE..AM NOW NEGATIVE,, AM A LIVING WITNESS..I DON'T KNOW HOW TO THANK THIS MAN? I JUST WANT TO HELP OTHERS IN ANY WAY I CAN.. I HAVE JOINED MANY FORUMS AND HAVE POSTED THIS TESTIMONIES AND ALOT OF PEOPLE HAS MAIL AND CALLED THIS MAN ON PHONE AND AFTER 2 DAYS THEY ALL CONFIRMED NEGATIVE.. BBC NEWS TOOK IT LIVE AND EVERY EVERYBODY SAW IT AND ITS NOW OUT IN PAPERS AND MAGAZINES THAT THERE IS A HERBAL CURE FOR HIV AND ALL WITH THE HELP OF THIS MAN,, IF YOU WISH TAKE IT OR NOT..GOD KNOWS HAVE TRIED MY BEST. ABOUT 28 PEOPLE HAVE BEEN CONFIRMED NEGATIVE THROUGH THE HERBAL CURE OF DR.USIFOH. AND THEY SEND MAILS TO THANKS ME AFTER THEY HAVE BEEN CONFIRMED NEGATIVE,,THIS MAN IS REAL..DON'T MISS THIS CHANCE,,HIV IS A DEADLY VIRUS,,GET RID OF IT NOW.. If there is anyone who has similar problem and still looking for a way out, his email still remains  drusifohherbalhome@gmail. Com OR ADD HIM UP ON WHATSAPP +2348136788465 I  heard some one saying that he was free from mental disorder through the sameDR USIFOH

    ReplyDelete


  24. Thanks for sharing such an informative article. SSB medicare pvt is leading dealer and distributor of medical equipments. For oxygen level disorder you can buy oxygen concentrator online
    contact - 8400600800 or 8400700500 at most affordable cost or you can also purchase it on rent.

    ReplyDelete
  25. After having a persistent cough for over a year, I was diagnosed with COPD
    in March 2015. In 2016 my COPD got worse to the point where not only do I
    have trouble sleeping at night, I also struggle to get air into my lungs. I
    read in a health forum of a herbal centre (native health clinic) who have successful treatment to COPD/Emphysema, i immediately
    contacted the herbal centre via their website and purchased the COPD herbal
    remedy, I used the remedy for 2 weeks, all my symptoms were reversed, i did
    another test for confirmation, i was declared COPD free. email (
    nativehealthclinic@gmail.com) or WhatsApp/Call him on +2348140073965

    ReplyDelete
  26. I just experience the wonders of Dr ovia herbs. God will continue to bless you Dr ovia more abundantly for the good work you are doing in peoples life by curing them from different type of diseases. I will keep on testifying about your good work. I was living with diabetes type 1      6 months ago and my doctor told me that there is no cure. I did not believe him and i keep my faith up hoping that one day i will be cured from this horrible disease. One day i saw a post on diabetes forum about a herbal doctor called Dr ovia on how he cure people from diseases with his root and herbs and i quickly contact Dr ovia  on his email and explain my problem to him and he told me not to worry that he is going to cure me and truly he prepared the herbal medicine and send it to me through UPS and gave me instructions on how to take it. After three weeks of taken the herbal medicine , i went to my doctor for checkup and my  diabetes result show Negative and my doctor told me that there is no trace of diabetes in my body and the diabetes is completely gone You can also be cured from any type of diseases by contacting Dr ovia on his email: droviaherbalhome@gmail.com or WhatsApp him on +2348117923986You can follow his page droviaherbalhome

    ReplyDelete
  27. Hello viewers around the Globe, I was despondent because i had a very small penis, about 2.5 inches soft and 4 inches hard not nice enough to satisfy a woman, i have been in so many relationship, but cut off because of my situation, i have used so many product which doctors prescribe for me, but none could offer me the help i searched for. i saw some few comments on the INTERNET about this specialist called Dr,MOSES and decided to contact him on his email: Dr.mosesherbalisthome@gmail.com) so I decided to give his herbal product a try. i emailed him and he got back to me, he gave me some comforting words with his herbal pills for Penis Enlargement, Within 3 week of it, i began to feel the enlargement was surprised when she said that she is satisfied with my sex and i have got a large penis. Am so happy, thanks to Dr MOSES I also learn that Dr MOSES also help with Breast Enlargement Hips and Bums Enlargement etc.. If you are in any situation with a little Penis, weak ejaculation, small breast_hips_bums do get to Dr MOSES now for help on his email (Dr.mosesherbalisthome@gmail.com) or add him on whatsapp line +2348109374702..............
    HE ALSO CURE THE FOLLOWING ........ HERPES VIRUS........... HPV VIRUS........ WEAK ERECTION ............
    . PREMATURE EJACULATION.............
    . LOW SPERM COUNT.....................

    ReplyDelete

  28. I am from New York. I was in trouble when doctor told me that I have been diagnosed tinnitus ringing ears with … I though about my Family, I know my Family will face a serious problem when I’m gone, I lost hope and I wept all day, but one day I was surfing the Internet I found Dr. Oyakhire contact number. I called him and he guided me. I asked him for solutions and he started the remedies for my health. Thank God, now everything is fine, I’m cured by Dr. Oyakhire herbal medicine, I’m very thankful to Dr. Oyakhire and very happy with my hubby and family. email him on droyakhire7@gmail.com OR contact his whatsapp number: +2349039208180 DOCTOR OYAKHIRE CAN AS WELL CURE THE FOLLOWING DISEASE:- 1. HIV/AIDS 2. HERPES 3. CANCER 4. ALS 5. DIABETES 6. HEPATITIS

    ReplyDelete
  29. I was infected with Genital Herpes Virus 10 month ago, ever since then i have been searching for cure everywhere because i was feeling so uncomfortable with it. I have been dating for almost 5 years until i contracted Genital Herpes from my ex-boyfriend. since then I became very  sad about the whole situation, always going online checking if i could get a cure to Genital Herpes, then i came across so many testimonies. Due to my seriousness and eagerness to be completely cured, i became a victim of fraud after contacting several so-called herbal doctors i was referred to. I lost a lot of money but i didn't stop searching for a cure. Then one faithful day, i came across a testimony of a lady saying that she got her Genital herpes cured by a Great Herbal Doctor she called Dr iniboku by contacting him through his email address. And she advised anyone with Genital Herpes or Simplex Herpes to contact the herbal doctor for Herbal Cure. I contemplated for about 4 hours whether or not to contact him. then something inside of me told me 'Nothing good comes easy'. I then contacted him through his email and told him my problem. He told me all the things I needed to do and also gave me instructions to follow, which i did properly. Just within weeks of drinking and applying the herbal medication he sent to me through DHL delivery service, i started seeing changes, i went to my medical doctor for check-up, i was so happy when the doctor told me i was no more having Genital Herpes Virus, it was all tears of Joy from that moment, People think herpes is really a minor skin irritation herpes has a long term effects on health and if i could ever meet a Genuinely Great Herbal Doctor. I'm so grateful to him. i am completely free from Genital Herpes Virus, i introduced a family friend who have Simplex Herpes virus to him, He called me and told me he was also cure completely. I promised to share my own testimony like that of the lady on the internet. Friends, If you are also struggling with Herpes disease you can as well Contact him via Email: drinibokuspelltemple@gmail.com him on via whatsApp at +2347059186346

    ReplyDelete
  30. CURED FROM GENITAL HERPES  AFTER USING DOCTOR HAZIM HERBAL MEDICINE CONTACT HIM VIA WHATSAPP +234905826857
    Herbal supplements have existed for thousands of years and can be traced over several different cultures. For now. Herbs are now used to cure diabetics, herpes, chronic pain, asthma,hepatitis b, cancer , ALS , Ovarian Cyst and even  GENITAL HERPES. I like herbs so much. Most of the time, the injection and the drug are only a loss of duration. I was cured of GENITAL HERPES   last year with the use of herbs, I suffered from GENITAL HERPES   for 13 years, but with the help of DR. Hazim Usman  Herbal Medicine, I was cured in a few weeks of using the herbs he sent me by UPS Service Delivery. I don't know the kind of health problem you are facing right now, but I assured you that you will be cured if you contact Dr. Hazim Usman and explain your problem to him, that the issues will resolve in a few weeks , contact Dr. Hazim Usman by his e-mail address:-----( usmandrhazim@gmail.com )-----or reach him via
     WHATSAP number---( +2349058026857)---

    ReplyDelete
  31. Battling with any health related issues or infection is not the end of your life, why not contact a herbal practitioner for cure Dr Ogedegbe has herbal remedies and permanent solution for all your health related problems.I recommend him to you today only because i have also used his herbal medicine and it worked perfectly on my health problem, you can actually save yourself from giving your hard earned money to Scammers if only you can contact Dr Ogedegbe today for genuine and Permanent cure herbal products . Pls help share this post to save yourself and your love ones.Dr Ogedegbe is specialize in these areas,Permanent herbal supplements for anxiety and depression,HIV/AIDS, DIABETES, HERPES, PENIS ENLARGEMENT, CANCER, HPV, ALS.  .. etc. Email: dr.ogedegbe6@gmail.com also call or whatsApp him on +2348109374702...........

    ReplyDelete
  32. Last year I started on COPD formula treatment from Dr Oduwa Herbal Home, the treatment worked incredibly for my lungs condition. I used the herbal treatment for almost 5 months, it reversed my chronic obstructive pulmonary disease. My severe shortness of breath, dry cough, low energy, fatigue, chest tightness and others gradually disappeared. Visit Dr Oduwa Herbal Home official web page https://droduwaherbalhome.com/. This COPD treatment has improved the quality of my life greatly, i breath much better and It feels comfortable























































    Last year I started on COPD formula treatment from Dr Oduwa Herbal Home, the treatment worked incredibly for my lungs condition. I used the herbal treatment for almost 5 months, it reversed my chronic obstructive pulmonary disease. My severe shortness of breath, dry cough, low energy, fatigue, chest tightness and others gradually disappeared. Visit Dr Oduwa Herbal Home official web page https://droduwaherbalhome.com/. This COPD treatment has improved the quality of my life greatly, i breath much better and It feels comfortable

    ReplyDelete
  33. i m 'here to testify about the great work of Dr Isibor. I have been suffering from (HERPES) disease for the past 5 years and had constant pain, especially in my knees. During the first year,I had faith in God that i would be healed someday.This disease started circulating all over my body and i have been taking treatment from my doctor, few weeks ago i came across a testimony of one lady on the internet testifying about a Man called Dr Isibor on how he cured her from Herpes Simplex Virus. And she also gave the email address of this man and advised anybody to contact him for help for any kind of sickness that he would be of help, so I emailed him telling him about my (HERPES Virus) he told me not to worry that i was going to be cured!! Well i never believed it,, after all the procedures and remedy given to me by this man few weeks later i started experiencing changes all over me as Dr Isibor assured me that i will be cured,after some time i went to my doctor to confirmed if i have be finally healed behold it was TRUE, So friends my advice is if you have such sickness or any other at all you can contact Dr isibor via email:drisiborspellhome@gmail.com or you can call or whatsApp his mobile number  +2348110493039 

    ReplyDelete
  34. i m 'here to testify about the great work of Dr Isibor. I have been suffering from (HERPES) disease for the past 5 years and had constant pain, especially in my knees. During the first year,I had faith in God that i would be healed someday.This disease started circulating all over my body and i have been taking treatment from my doctor, few weeks ago i came across a testimony of one lady on the internet testifying about a Man called Dr Isibor on how he cured her from Herpes Simplex Virus. And she also gave the email address of this man and advised anybody to contact him for help for any kind of sickness that he would be of help, so I emailed him telling him about my (HERPES Virus) he told me not to worry that i was going to be cured!! Well i never believed it,, after all the procedures and remedy given to me by this man few weeks later i started experiencing changes all over me as Dr Isibor assured me that i will be cured,after some time i went to my doctor to confirmed if i have be finally healed behold it was TRUE, So friends my advice is if you have such sickness or any other at all you can contact Dr isibor via email:drisiborspellhome@gmail.com or you can call or whatsApp his mobile number  +2348110493039 

    ReplyDelete
  35. i m 'here to testify about the great work of Dr Isibor. I have been suffering from (HERPES) disease for the past 5 years and had constant pain, especially in my knees. During the first year,I had faith in God that i would be healed someday.This disease started circulating all over my body and i have been taking treatment from my doctor, few weeks ago i came across a testimony of one lady on the internet testifying about a Man called Dr Isibor on how he cured her from Herpes Simplex Virus. And she also gave the email address of this man and advised anybody to contact him for help for any kind of sickness that he would be of help, so I emailed him telling him about my (HERPES Virus) he told me not to worry that i was going to be cured!! Well i never believed it,, after all the procedures and remedy given to me by this man few weeks later i started experiencing changes all over me as Dr Isibor assured me that i will be cured,after some time i went to my doctor to confirmed if i have be finally healed behold it was TRUE, So friends my advice is if you have such sickness or any other at all you can contact Dr isibor via email:drisiborspellhome@gmail.com or you can call or whatsApp his mobile number  +2348110493039 

    ReplyDelete
  36. I'm here to testify about the great work Dr Iyoha did for me. I have been suffering from (HERPES) disease for the past 3 years and had constant pain, especially in my knees. During the first year,I had faith in God that i would be healed someday.This disease started circulating all over my body and i have been taking treatment from my doctor, few weeks ago i came across a testimony of someone on the internet testifying about a Man called Dr Iyoha on how he cured her from Herpes Simplex Virus. And she also gave the email address of this man and advise anybody to contact him for help for any kind of sickness that he would be of help, so I emailed him telling him about my (HERPES Virus) he told me not to worry that i was going to be cured!! Well i never believed it, well after all the procedures and remedy given to me by this man which i take for 3 week,few months later i started experiencing changes all over me as Dr Iyoha assured me that i will be cured,after some time i went to my doctor to confirmed if i have be finally healed behold it was TRUE, So friends my advise is if you have such sickness or any other at all you can contact Dr Iyoha via email driyohasolutiontemple@yahoo.com. You can also call his telephone number on +1 407 337 9869. Thanks once again Dr Iyoha ...

    ReplyDelete
  37. I'm 61 years old, I contracted hpv in 2011' I has be taking lot treatment for it and embarrassed some months ago the wart stated coming out seriously, I used lot recommendation because there was lot warts around my anus and was so . but today I'm totally happy I got the virus eliminated by using natural treatment from Dr Onokun herbal center after his treatment I got cured. all the warts went away' seriously believed Dr Onokun he have the cure for human papillomavirus because he has eliminated hpv been in my body since 2011, Dr Onokun make it possible for me. Here is Dr Onokun email: dronokunherbalcure@gmail.com or website: https:// Dronokunherbalcure.wordpress.com/ page at: https://www.facebook.com/naturaltreatment1

    ReplyDelete

  38. I'm Ian Venamore I was diagnosed with chronic obstructive pulmonary disease (COPD) in my mid-fifties. Today I'm an active volunteer member of Lung Foundation Australia and chair of the associated COPD Patient Advocacy Group (CPAG).I also participates in international meetings with the goal to change the future of COPD recognition, diagnosis and treatment.I am a strong advocate for pulmonary rehabilitation and attends to gym classes “religiously.” I am also a firm believer in and proponent of patient education and self management. I obtain this cure from an Africa home of herbal roots for traditional treatment and they are 100% active and effective, which make it very difficult for science to discover or believe this traditionally cure, try your luck if you are CHRONIC OBSTRUCTIVE PULMONARY DISEASE Patient, their contact is as follow. healthmedlab@gmail.com OR info@healthmedlabclinic.com  their Website: www.healthmedlabclinic.com recommended by Ian Venamore their satisfied previous COPD cured patient a living witness. 

    ReplyDelete
  39. I was in the beginning of my own journey with COPD Emphysema at 48. I had LVRS (lung volume reduction surgery) a year later, which I am forever grateful for it actually led me to multivitamincare.org . I have read some of their stories online before using their natural herbal formula , I had very hard time breathing then, and even more so at night, it was so bad I can’t sleep. I get up with a tight chest that feels blocked and can’t breathe well at all,I was excused from normal life responsibilities but natural herbs from www multivitamincare.org really helped a but sometimes I think is God prodigy that I was able to treat my Chronic obstructive pulmonary disease but multivitamin care herbal formula has a big impact on my recovery because my heart condition has been fully reversed . They do things for me, and was too happy to comply with their service. This is a equitable of a way to get of your COPD emphysema .

    ReplyDelete
  40. I started on COPD/Asthma Herbal formula treatment from Akanni herbs centre , the treatment worked incredibly for my lungs condition. I used the herbal treatment for almost 5 months, it reversed my chronic obstructive pulmonary disease. My severe shortness of breath, dry cough, low energy, fatigue, chest tightness and others gradually disappeared. Visit Akanni herbs clinic official web page www. Akanniherbalcentre com. This COPD treatment has improved the quality of my life greatly, i breath much better and It feels comfortable!

    ReplyDelete
  41. I was introduced to Herbal HealthPoint and their successful COPD Herbal treatment, i immediately started on the treatment for my 6 years long Emphysema condition. The herbal treatment is incredible, my severe shortness of breath disappeared within the first month. Go to HealthPoint official web page w w w. herbalhealthpoint .c o m. This treatment improved the quality of my life and i am Emphysema free!  

    ReplyDelete
  42. started on the COPD treatment; a few weeks into the treatment I began to notice a reduction in symptoms, after I completed the treatment, my symptoms were all gone including the severe shortness of breath, cough and wheezing. Its been over two years since treatment. I feel better and breathe better. visit www. treeoflifeherbalclinic. com

    ReplyDelete
  43. I started on COPD Herbal treatment from Ultimate Health Home, the treatment worked incredibly for my lungs condition. I used the herbal treatment for almost 4 months, it reversed my COPD. My severe shortness of breath, dry cough, chest tightness gradually disappeared. Reach Ultimate Health Home via their website www.ultimatelifeclinic.com I can breath much better and It feels comfortable!

    ReplyDelete
  44. I grew up with asthma; I suffered sinus and respiratory infections my entire life. I started smoking at 16. When I was in my early 40s, my asthma was becoming increasingly worse. I was diagnosed with COPD at age 47. I am now 55. I quit smoking four years ago. The disease does not improve. My good days were far, i was scared that i wont survive it but i was so lucky to receive a herbal products from my step father who bought it while coming from South Africa for Rugby league, this herbal remedies saved me from this disease, at first it helps fight the symptoms of diseases and i was seeing good outcome, i had to use it for 13 weeks just as they Dr was prescribed and i was totally cure of asthma and COPD, (multivitamincare org ) do not hesitate to purchase from them they deliver across worldwide.

    ReplyDelete