Ipratropium / Atrovent Question

[AnthonyM83]

I was studying this med from three different sources.

AHA Flip Booklet Ped section lists:

Indications: Anticholinergic and bronchodilator for tx of asthma

Precautions: Pupil dilation in eyes

Inh. Dose: 250-500 mcg (by nebulizer, MDI) q 20 min, x3

My school's pharm booklet lists:

Ind: asthma, bronchospasms associtated with COPD

Contra: Pt has been administered Atropine

Precautions: Children under 12yro, narrow-angle glaucoma

Dose: Adult: .5 mg neb, Ped: N/A

This Clinician's Pocket Drug Ref guide I got lists:

Ind: Bronchospasm with COPD, rhinitis, rhinorrea

Contra: Allergy to soya lecithin

Prec: (Preg with inhaled insulin

Dose: 500 mcg, but only for Adults and Peds over 12.

Note: Not for acute bronchospasm

Now, I expect some variation from each source, but this is a bit more than usual.

The Pocket Ref is saying not to use it for acute bronchospasm (aka asthma)

AHA Guide is saying to use it in asthma, possibly first-line concurrently with albuterol (no mention of kids under 12...and it's in PALS section)

School guide only lists under 12 as precaution...and throws in the narrow-angle glaucoma.

I'm sure the answer is they are all right at times...but in general practical terms, what should I know about this drug???

-Is it used for acute asthma? (the Pocket ref is supposed to list unofficial indications, too)

-Is the kids under 12 a big deal? (PALS doesn't even mention it)

-What contraindications do you guys have?

Learning about drugs seems so difficult because each source is so different. There's no standard source for paramedics or prehospital care is there?

[tskstorm]

Pharmacology is dynamic, Things are always changing .. I don't see how there could be a standard book.

we have a contraindication of allergies to nuts or soy and contraindicated in pt's with hypersensitivity to atropine and its derivatives.

It is currently only in protocol for asthma locally further if approved by medical director you are to mix albuterol and ipratropium together.

There should be no problem in children under 12 we routinely give the adult dose to kids over 6y/o and a half dose to kids under 6y/o

[AnthonyM83]

Pharmacology is dynamic, Things are always changing .. I don't see how there could be a standard book.

But there ARE books that update yearly. It'd just be nice if they were either all updated similarly OR if there was a standard for prehospital care for providers to be on the same page with (so to speak).

Thanks for the ipratroprium info.

[VentMedic]

we have a contraindication of allergies to nuts or soy and

Outdated information.

This was true with ONLY the older MDI form with the CFC propellant. All Atrovent MDIs should be HFA and the soy allergy does NOT apply in any way to the liquid form of Atrovent or "Duoneb".

However, the soy (lecithin base) does still apply to the Combivent MDI (CFC) since it was granted a stay of execution by the FDA...at this time.

Here is powerpoint presentation of all the inhalers currently on the U.S. market. It might be wise to look through them since some GP MDs and EDs give them out like candy with little to no instruction. It is not uncommon for someone to mix up a LABA for a SABA and have serious consequences including death. As well, the inhalation techniques for administering MDIs have changed and we no longer float the canister in water to see how full it is.

http://www.asthmanow.net/EPR%203%20Asthma%...Medications.ppt

Here is how asthma is treated overall (probably more information than you wanted but it can tell you a lot about a patient by looking at the meds they are on and why.) The last section on exacerbations might be of interest.

EPR-3 (2007)

http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf

Here is another general overview of asthma treatments (again probably more info than you want.)

http://www.acep.org/WorkArea/DownloadAsset.aspx?id=44920

Now, for treatment, it depends on whether you medical director is reading the Asthma Guidelines EPR-2 or EPR-3 (2007 guidelines). It also depends on whether you are in Canada or the U.S., East Coast or West Coast, North or South, Northern CA or Southern CA, etc.

Some doctors will treat everything with a "Duoneb" or Albuterol/Atrovent combo. Some say it is a was of time for those with asthma and no other COPD component. The new guidelines do not stress Atrovent in asthma.

FACT: Atrovent by itself is NOT a RESCUE med.

Some do use it similar to a SABA as an alternative for maintenance.

However, there is very little data that indicates atrovent is effective in long term management of asthma.

If you do give Atrovent to a child in the field, document it clearly and make sure the MDs/RNs/RRTs at the ED are made aware of it. We do NOT like to give back to back doses of Atrovent to a pediatric or even an adult.

In summary there is not just one good answer because you will still have to do what your medical director puts in your protocol and he/she may not have had an update in the latest pulmonary meds in a long time.

BTW, let me thank the Canadians again for their attempt to save the ozone layer and messing up the asthma inhaler industry.

Edited May 5, 2009 by VentMedic

[CBEMT]

Interesting stuff. We're about to get Atrovent added to all of our protocols where Albuterol is mentioned. Even CHF.

[mobey]

BTW, let me thank the Canadians again for their attempt to save the ozone layer and messing up the asthma inhaler industry.

I am probably missing something.....

The reason we left Nebulizers and are now using inhalers is to prevent/reduce the spread of illness to the health care worker.

One of the lasting changes SARS brought about.... and now H1N1.

Perhaps an N95 while using a Neb would be as effective?

[VentMedic]

I am probably missing something.....

The reason we left Nebulizers and are now using inhalers is to prevent/reduce the spread of illness to the health care worker.

One of the lasting changes SARS brought about.... and now H1N1.

Perhaps an N95 while using a Neb would be as effective?

I was referring to the Montreal Protocol. Although it was formed from an international summit, it is just easier to blame the Canadians because of the name as a little insider industry joke.

The switch to HFA has brought alot of problems concerning the reformulation of the meds. Combivent is now having issues with reformulating and it may still go away if it can not.

It also scraps years of research for the MDI vs Neb debate as now the velocity and weight of the particles appear different. Different delivery methods will again have to be repeatedly tested to see if there is actually no difference. However, the new canisters have made it difficult to adapt many of the MDIs to a ventilator or BVM circuit so it is difficult to even use in the same way as before. Long term MDI users are now preferring nebs in the ED where before we did give MDIs for rescue. They are not feeling the same force and coolness of the "freon" propellant and so they believe it is not effective. Also, the HFA MDIs are recommended to be taken with a spacer or holding chamber which many do not want. And, the open mouth/2 finger technique is no longer advised so timing for the closed mouth technique must be near perfect which is difficult to do at times of distress or for a new user in the ED.

In the ICUs we have had to add nebs to our ARDS protocol again even though it goes against the VAP (Vent Associated PNA) precautions and if one does not use a spring loaded adapter in line to prevent opening the vent circuit, it defeats the purpose of running high levels of PEEP. This again is due to the redesign of the canisters that are difficult to adapt with the circuit.

Edited May 5, 2009 by VentMedic

[AnthonyM83]

Hey Venti,

I'm definitely going to read through the asthma protocols...but for short-term resolution, any idea why one of the drug references would specifically say "not for acute bronchospasm" in the notes section? Would that be where EPR-2 versus EPR-3 comes in? You mentioned some don't think it helps in long-term treatment...but any ideas why it would almost be contraindicated in one reference?

[tniuqs]

I was referring to the Montreal Protocol. Although it was formed from an international summit, it is just easier to blame the Canadians because of the name as a little insider industry joke.

Hey Hey thats Montreal Protocol ... those French Canadian freaks ... LOL>

[VentMedic]

Hey Venti,

I'm definitely going to read through the asthma protocols...but for short-term resolution, any idea why one of the drug references would specifically say "not for acute bronchospasm" in the notes section? Would that be where EPR-2 versus EPR-3 comes in? You mentioned some don't think it helps in long-term treatment...but any ideas why it would almost be contraindicated in one reference?

Look at the mechanism of action. Atrovent is an anti-cholinergic and not a beta-adrenergic agonist. Its affects on the airways is not as quick and may not have any effect for some.

Long term anti-cholinergic use has come under controversey lately but that has also come with the newer long acting forms.

http://www.news-medical.net/?id=41663

None of this will probably have any affect on prehospital care because you may not have the information to determine if you are only treating asthma or some other COPD component. Thus, some will just give Albuterol/Atrovent as a blanket with the anti-cholinergic possibly having some effect on the airways.

I posted the Asthma guidelines just to show you it is not juat a random "give this med" type protocol. The guidelines offer many options to fit the treatment with the patient. However, again this is not possible in the field but looking at the meds may give you some idea of their severerity...provided they are under the care of a Pulmonologist. Often patients that go the ED and/or GPs get a hand full of samples and just take the meds without adequate instruction or any reason for taking them. We have patients come to the ED who are taking Advair, Symbicort, Flovent, Serevent, Albuterol, Combivent and Proventil at one time because they have no idea what they are taking. Their doctor just handed them a bunch of inhalers at the office.