Should IV Ventolin be considered for suspected H1N1 patients?

[mobey]

The only company I know of that carries I.V. ventolin is Parkland Ambulance here in Ab.

Unfortunatly I know nothing of thier protocol. If someone is interested in researching that would be a good spot to start.

[tniuqs]

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

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

Less effective than what would be my first query.

Ventolin is a drug that is very effective with not only asthma but asthmatic response ie histamine release by "J" receptors in the lung, the old terminology was Asthmatic Bronchitis btw and describes this far better. YES ventolin should be used on H1N1 is there is an asthmatic / bronchospasm response ... but here in lies the problem:

The release of possible contaminated droplets into the surrounding environment, hence increasing risk to caregivers (especially in a confined area)as the partical size generated by a SVN is .2 to 10 microns and this is the most optimal range to find its way into the terminal bronchiole(s).

There are devices out in goggle land that can and do use a sealed system with hepa type filter on exhalation ... but they ain't cheap, if a patient is ventilated ie "tubed" then a DAR filter should be used on the flow diverter (exhalation side)

As for IV ventolin .. brother mobey is Parkland using 250 mics IV or using a Drip ? it is a big hammer administering Ventolin this route and usually reserved for extremus both concepts have lost favour in the EMS community and are not included in the new Improved 'Alberta Health Protocols' to the best of my knowledge and just where are those elusive documents with this "transition" ? ... sheesh.

I recently attended a Respiratory geek thingy meeting and the main topic was ISOLATING the patient, all laughed at the suggestion of coughing in ones arm, bawhhaa using isolation techniques and not emphasizing REVERSE isolation to care givers is like closing the barn door after the horse is bolted so all suspected patients should have the N95FIRSTthen comes the issue of the valved exhalation "approved N 95 ?" and then fit testing, have you seen anything other than an ADULT N 95 ? Then how they are going to sterilize the guts of the new Newport Transport/MCI Ventilators post patient use is a bit of a quandary too, the Canadian Government bought 500 of them unfortunately they need a few more bloody beds/rooms and RN and RRT staff available first so just who is going to run them ... ain't it the government way.

Cloning was an option I suggested .... te he.

Edited October 6, 2009 by tniuqs

[VentMedic]

Then how they are going to sterilize the guts of the new Newport Transport/MCI Ventilators post patient use is a bit of a quandary too, the Canadian Government bought 500 of them unfortunately they need a few more bloody beds/rooms and RN and RRT staff available first so just who is going to run them ... ain't it the government way.

.

Newports? No real vents available in Canada?

The U.S. is stockpiling LTV 1200s for their disasters. If anyone is interested, there is a decent 1.5 hour inservice on it at:

http://www.aarc.org/headlines/09/09/webcast_training.cfm

We do some serious filtering at the machine side and are using the HMEs that have a good micron filter rating for the exhalation to protect the HCWs.

One CCT in California was discovered to be running dirty vents for antibiotic resistant microbes due to not using any filters to protect their ventilators. They also were doing NOTHING to protect their staff from exhalation gas, droplets or whatever. I still see many teams, including flight, that fail to protect their technology or themselves.

[Dustdevil]

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

The first inclination of the kinder, gentler Dustdevil was to leave this alone. But then I noticed our friend lurked here for over four years just to make that first post. Seriously? That is what finally brought you out of lurking?

[rock_shoes]

There are devices out in goggle land that can and do use a sealed system with hepa type filter on exhalation ... but they ain't cheap, if a patient is ventilated ie "tubed" then a DAR filter should be used on the flow diverter (exhalation side)

I think this will likely be a more appropriate solution for the time being. I wonder if the greater incidence of adverse effects with IV ventolin is due primarily to the IV administration, the severity of illness in the patients this delivery route is currently used on, or some combination of the two? What about a single IV push versus a continuous infusion? So many questions and I suspect the answers won't come soon enough to be of much use dealing with H1N1.

As for IV ventolin .. brother mobey is Parkland using 250 mics IV or using a Drip ? it is a big hammer administering Ventolin this route and usually reserved for extremus both concepts have lost favour in the EMS community and are not included in the new Improved 'Alberta Health Protocols' to the best of my knowledge and just where are those elusive documents with this "transition" ? ... sheesh.

I would be interested in knowing the results in Parkland as well. Hopefully Parkland has kept close tabs on the results of using IV ventolin as I'm sure the information would be valuable.

I recently attended a Respiratory geek thingy meeting and the main topic was ISOLATING the patient, all laughed at the suggestion of coughing in ones arm, bawhhaa using isolation techniques and not emphasizing REVERSE isolation to care givers is like closing the barn door after the horse is bolted so all suspected patients should have the N95FIRSTthen comes the issue of the valved exhalation "approved N 95 ?" and then fit testing, have you seen anything other than an ADULT N 95 ? Then how they are going to sterilize the guts of the new Newport Transport/MCI Ventilators post patient use is a bit of a quandary too, the Canadian Government bought 500 of them unfortunately they need a few more bloody beds/rooms and RN and RRT staff available first so just who is going to run them ... ain't it the government way.

Cloning was an option I suggested .... te he.

Common sense says no valved exhalation for the patient. Of course that could just be me. We actually carry several sizes and types of N95s. Some valved some fold-flat etc.. Did AHS purchase all of these Newport Transport Ventilators without ensuring they could be sterilized or are there not enough trained people to sterilize them properly?

[tniuqs]

Newports? No real vents available in Canada?

The U.S. is stockpiling LTV 1200s for their disasters. If anyone is interested, there is a decent 1.5 hour inservice on it at:

http://www.aarc.org/headlines/09/09/webcast_training.cfm

We do some serious filtering at the machine side and are using the HMEs that have a good micron filter rating for the exhalation to protect the HCWs.

One CCT in California was discovered to be running dirty vents for antibiotic resistant microbes due to not using any filters to protect their ventilators. They also were doing NOTHING to protect their staff from exhalation gas, droplets or whatever. I still see many teams, including flight, that fail to protect their technology or themselves.

Hey don't shoot the messenger ... thing is the government did not consult me because I love the LTV maybe the thinking was oh well they don't have enough beds to cover anyway or those affected by H1N1 will not need anything more than AC or PS or just underbid and let the bean counters decided ? I dunno.

And yes most of the flight teams here in AB use zip for patient circuit isolation ... can lead a horse to water but can't make it drink I guess. It is not for lack of trying ...

As for sterilization ... internal circuity dunno its the first time I have even seen the Newport, it was mentioned about training but not too many critical care RRTs would need more that 10 minutes to figure that vent out.

Self check is push the turn me on button twice.

cheers

[flight-lp]

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.

Ironic that you mention this as our ground CCT team was discussing this for our 1200. We are testing several filters with varying results, however if you have suggestions, I'm all ears.

[scubanurse]

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.

Thank you for clearing that up.

[VentMedic]

Thank you for clearing that up.

Here is a good reference with a visual for the oxygen masks and the potential for spreading disease.

Dispersal of Respiratory Droplets With Open vs Closed Oxygen Delivery Masks*

http://chestjournal.chestpubs.org/content/125/3/1155.full

[VentMedic]

Ironic that you mention this as our ground CCT team was discussing this for our 1200. We are testing several filters with varying results, however if you have suggestions, I'm all ears.

The ThermoFlo (ARC Medical), Drager TwinStar and the Hygrobac S (used to be Nellcor(?)) are so far the ones that seem to do the job with the less problems.