Should IV Ventolin be considered for suspected H1N1 patients?

[rock_shoes]

With the upcoming flu season I've been thinking about things we do that become high risk when dealing with droplet transmission illnesses. The preferred method for Ventolin (Albuterol, Salbutamol, pick your favourite name/brand) administration is via nebulizer in most services I'm aware of. This becomes problematic when dealing with a suspected H1N1 patient due to the nature of how it's spread. This doesn't mean that we should fail to treat these patients however.

All that said, I began to think about the possibility of IV Ventolin administration. Thus far the downsides found in my recent searches include greater risk of tachycardia, hypokalemia, cardiac dysrythmias, and elevation of BGL. Does anyone use IV Ventolin in their service? If so how effective has it been? What has the prevalence of adverse affects been like? Any links to relevant research and studies are welcome.

Edited October 6, 2009 by rock_shoes

[RavEMTGun]

Umm... how bout using a new neb each time? What's the problem here?

IV ventolin? For respiratory? Sounds less effective and more dangerous...

[DwayneEMTP]

Umm... how bout using a new neb each time? What's the problem here?

I'd be willing to bet that he's referring to a possible increased risk of transmission from the exhaled neb. In the future you might want to reach a little and begin by assuming that the poster is not an idiot. To imply that reuse of his disposable nebulizer was the crux of his issue is short sighted, and a little silly.

IV ventolin? For respiratory? Sounds less effective and more dangerous...

Again, I don't believe he was asking for an opinion as to how 'it sounds' but for people that have experience with it and can offer an educated opinion.

Not trying to bust you chops brother, but you've made a poor start...

Most of us did when we were new here. Welcome, and I hope you'll stick around.

Dwayne

[VentMedic]

You do bring up a good topic as many are trying to come up with safe and effective delivery systems for nebulized meds and O2 without risking exposure to others. We do not have that many isolation areas in the EDs or even in some hospitals.

IV Albuterol is approved in Canada and a few other countries but not in the U.S. I believe a few years ago IV Albuterol was part of EMS protocols in at least one area of Canada. There is some research for it, and that includes what was also done in the U.S., but it is inconclusive as far as it being a better bronchodilator than the nebulized or other IV medications. Of course the side effects such as hypokalemia are beneficial to some patients more than the nebulized form but also has other potential complications.

Nebulizing meds and O2 devices allowing exhaled particles into the surrounding area has been especially controversial since the recent SARS and in years past with TB becoming prevalent in some areas. We do have filtered nebs which have been used for Pentamidine and some of the antibiotics which offer some protection. Simple masks, NRBMs and definitely BiPAP/CPAP devices are in question. There is a recent editorial in the Canadian Medical Journal concerning the use of BiPAP/CPAP as it may prevent intubation in some Influenza A patients. However, the patients I have seen lately need to go straight to a High Frequency Ventilator for ARDS. In the hospital we can use a closed limb system with filters for BiPAP/CPAP by using a nonvented mask with the ICU ventilators. We are also trying to determine which filter is most effective with least resistance for our transport ventilators such as the LTV which can also be used for BiPAP/CPAP.

[scubanurse]

Vent raised a point about the use of non-rebreathers that I think makes sense to me. If we attach the neb to a non-rebreather than the exhaled droplets should be relatively contained right? Also a technique I do for asthma patients is double back the blue part of the neb and tape it down so the patient will breath some of the excess neb through the nose. Not sure if it actually does help but I would like to think that it can't hurt? Correct me if I am wrong..

and I second Dwaynes comment... never assume anything here cause you make an ass outta you and me!

[joesph]

ok just to be a total screw ball what could be done to control the exhaled resperations. you don't have to remove it from the room but just control the droplets in it. Is that possible or practical?

[VentMedic]

Vent raised a point about the use of non-rebreathers that I think makes sense to me. If we attach the neb to a non-rebreather than the exhaled droplets should be relatively contained right? Also a technique I do for asthma patients is double back the blue part of the neb and tape it down so the patient will breath some of the excess neb through the nose. Not sure if it actually does help but I would like to think that it can't hurt? Correct me if I am wrong..

The NRBMs offer NO protection at all and were actually mentioned as part of the problem for the spread of SARS at one hospital in China during the 2003 outbreak.

Filtered nebs offer some protection but the healthcare providers should be wearing an N95 mask when near the patient. The neb can also be turned off briefly when moving through an area that exposes other patients or staff.

For flu symptoms with no pre-existing pulmonary history, we find the nebulized bronchodilators do very little for breathing problems caused by the infiltrates.

ok just to be a total screw ball what could be done to control the exhaled resperations. you don't have to remove it from the room but just control the droplets in it. Is that possible or practical?

Patients that have influenza A are isolated. This is nothing new. If they require a NRBM or BiPAP/CPAP, they are put in a room that is capable of negative flow.

Edited October 6, 2009 by VentMedic

[Just Plain Ruff]

Well, droplet precautions should always be taken. That's a given.

How bout when you are going to give a breathing treatment and you suspect, SARS or N1H1 or just the flu that you yourself don a mask - not a n95 one but a mask approved for droplet protection.

If you proactively protect yourself then you proactively protect your family and the people you come into contact with.

So the sensible thing to do is to protect yourself, your partner and disinfect your ambulance after each patient.

[VentMedic]

Well, droplet precautions should always be taken. That's a given.

How bout when you are going to give a breathing treatment and you suspect, SARS or N1H1 or just the flu that you yourself don a mask - not a n95 one but a mask approved for droplet protection. If you proactively protect yourself then you proactively protect your family and the people you come into contact with.

So the sensible thing to do is to protect yourself, your partner and disinfect your ambulance after each patient.

The recommendations are for an N95 mask and not the surgical mask that had previously been used for the flu or droplet precautions.

http://www.ama-assn.org/amednews/2009/09/14/prsa0914.htm#

[rock_shoes]

Our current precautions for SARS, H1N1, etc. are in line with best known practices. Isolation gown, gloves, N95, eye protection and proper don and doff procedures for medics. Surgical masks for patients. We also have the option of moving to full tyvek suits and double glove in the future if neccessary. We do have inline viral filters for the BVMs. The procedure is to notify the hospital as far in advance of the incoming patient as possible so that they can prepare a negative pressure room (assuming the hospital has such a room). Post call the ambulance gets a complete deep clean and both the medic and driver change into fresh uniforms.