Should IV Ventolin be considered for suspected H1N1 patients?

[VentMedic]

What is surprising that PALS has jumped on this EPI bandwagon for all croup ... and I am so not a fan of putting BPs and heart rate into the troposphere.

cheers

For croup, Racemic Epi has been a frontline med. For RSV, it has been controversial but is in our protocols for rotation with either albuterol or levalbuterol.

[tniuqs]

For the patients' benefit, several of our EDs have gone to giving MDIs instead of the nebulizers. The ED can dispense meds so the patient doesn't need another script and then have to find the cash and pharmacy for another MDI. They will have their medication to last for a few days. Getting meds is often the problem here in the US with the lack of insurance especially now with the high unemployment rate.

Yup funny how that works, so many Asthmatics forget or can't afford to have a spare MDI on hand, a hospital visit is far more costly, and the patients are typically far worse, and besides those MDIs are single patient use and I keep losing them in a patients pocket whats this script for dispense thing ...must be american .. I know it reduces re:admissions to ER too.

cheers

For croup, Racemic Epi has been a frontline med. For RSV, it has been controversial but is in our protocols for rotation with either albuterol or levalbuterol.

Kristjansson S, Berg-Kelly K, Winso E. Inhalation of racemic epi in treatment of mild to moderately severe croup. Acta Paediatri 1994;83:1156-1160

This is a study based on Racemic vs Placebo, I know off topic but I am of the opinion that inhaled steroids are far more beneficial, and Ventolin with ipatromium bromide are with far fewer side effects and longer acting.

cheers

Edited October 8, 2009 by tniuqs

[VentMedic]

This is a study based on Racemic vs Placebo, I know off topic but I am of the opinion that inhaled steroids are far more beneficial, and Ventolin with ipatromium bromide are with far fewer side effects and longer acting.

cheers

We don't use it for bronchodilation but rather for vasoconstriction of the inflamed area. We also do an epi with or without lido mix emergently for a traumatized throat from extubation if it wasn't planned or the cuff leak measurement fooled us.

The epi properties we are hoping for are the same as when we use it for a site prep for a biopsy during a bronchoscopy or when the "bite" has bitten a bleeder.

Steroids can also be given inbetween treatments as well as IV without enhancing side effects of the epi. Essentially we just want to buy time for the IV steroids to work without intubation which can get knarly when the airway is closing on a child. The kid has to go down and out with the tube in almost simultaneously and it will be a small tube which will make the ventilator period a B%&*h.

Racemic Epi and my favorite...HeliOx

http://pediatrics.aappublications.org/cgi/content/abstract/107/6/e96

Safety and Efficacy of Nebulized Racemic Epinephrine in Conjunction With Oral Dexamethasone and Mist in the Outpatient Treatment of Crouphttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WB0-4HG68T9-6&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1039306228&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=d9d361f2be196b2f01056a0661954a0c

The management of croup

http://bmb.oxfordjournals.org/cgi/content/abstract/61/1/189

Good overview with x-ray and decent references cited at the end.

Viral Croup

http://www.aafp.org/afp/20040201/535.html

[tniuqs]

Vent ... this does bring up an interesting point maybe we should be asking if inhaled steroids decrease hospitalization/ admissions for H1N1 patients.

The big question for me remains WHO kissed the Pig in the first place ?

[VentMedic]

Vent ... this does bring up an interesting point maybe we should be asking if inhaled steroids decrease hospitalization/ admissions for H1N1 patients.

The big question for me remains WHO kissed the Pig in the first place ?

Once we get the H1N1 patients out of the ED and into the ICU they may not get another bronchodilator unless the do have a pre-existing pulmonary condition that might warrant it. We go straight for an ARDS protocol if there are infiltrates present and if the O2 index warrants, we go for the serious technology:

HFOV 3100B

http://lane.stanford.edu/portals/forms/High_frequency_oscillator_ventilation.pdf

Once the patient is on this, we won't break the circuit for a nebulizer. Steroids are also controversial in ARDS.

[tniuqs]

Once we get the H1N1 patients out of the ED and into the ICU they may not get another bronchodilator unless the do have a pre-existing pulmonary condition that might warrant it. We go straight for an ARDS protocol if there are infiltrates present and if the O2 index warrants, we go for the serious technology:

HFOV 3100B

http://lane.stanford.edu/portals/forms/High_frequency_oscillator_ventilation.pdf

Once the patient is on this, we won't break the circuit for a nebulizer. Steroids are also controversial in ARDS.

Nice power point but I think oscillation is a tad out of the league of most viewers, that said no harm, but are not the deaths we are observing due to underlying medical conditions and secondary bacterial infections (not that ARDS is NOt a serious consideration) and pregnancy ..i believe last count in the US was 28 fatalities in pregnant patients ?

[VentMedic]

Exacerbation of pre-existing conditions and other infections such as MRSA are expected with the regular Infuenza B season. Influenza A will quite often present with respiratory complications such as PNA of various etiologies and ARDS is now the issue in younger populations. If you have a patient with suspected flu that is having difficulty breathing to where you are considering IV Ventolin and no pre-existing pulmonary hx, there is a good possibility HFOV, Nitric Oxide and even ECMO could be in their future. A ventilator of sometype will probably be needed. This is where BiPAP/CPAP was thought to be of use in the initial phase to prevent intubation but the devices used by EMS and the single limb circuits with vented masks pose an infection control problem.

While the numbers for deaths are relatively small compared to the total number of flu cases, they are significant for the cause and the targets.

U.S. numbers so far:

http://www.cdc.gov/flu/weekly/

http://www.cdc.gov/h1n1flu/updates/us/

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0710a1.htm

Good case studies from Australia.

http://www.mja.com.au/public/issues/191_03_030809/kau10748_fm.pdf

Of course the challenge is getting patients from the less equiped hospitals to one with the resources safely for patient and crew. Thus, the filter conversation for the ventilators and masks for both patient and health care provider.

Edited October 8, 2009 by VentMedic

[kohlerrf]

Rock

I think you bring up a very good point. Too long have we been exposed to exhaled pathogens (it was TB in my day)and scooby, I think you offer a good "plan B" however the preferred is to not have air born droplets at all. I'm sorry I don't have experience with IV ventolin in addition I was always taught that nebulized and inspired it had its shortest onset and therefore sooner correction of the presenting problem. It may just be myth I don't know. I'm wondering if IV Ventolin is the best solution or having the practitioner put on an N-95 mask when treating a suspected respiratory infection? There are some inherent risks in our business.I am embarrassed to admit that when I started we never wore gloves and were sticking dirty needles in the bench seat cushion. In any event I'm going to start wearing our n-95's thanks.

[rock_shoes]

Well I've started into the reasearch. So far it's actually looking like Terbutaline might be a better option for IV administration than Albuterol but still reserved for the more severe cases. Here are some of the studies I've come across so far.

Comparison of inhaled and intravenous terbutaline in acute severe asthma.

Continuous intravenous terbutaline for pediatric status asthmaticus

Continuous intravenous terbutaline infusions for adult patients with status asthmaticus.

Comparison of nebulized and intravenous terbutaline during exacerbations of pulmonary infection in patients with cystic fibrosis

The dose-response effects of terbutaline on the variability, approximate entropy and fractal dimension of heart rate and blood pressure

Rock

I think you bring up a very good point. Too long have we been exposed to exhaled pathogens (it was TB in my day)and scooby, I think you offer a good "plan B" however the preferred is to not have air born droplets at all. I'm sorry I don't have experience with IV ventolin in addition I was always taught that nebulized and inspired it had its shortest onset and therefore sooner correction of the presenting problem. It may just be myth I don't know. I'm wondering if IV Ventolin is the best solution or having the practitioner put on an N-95 mask when treating a suspected respiratory infection? There are some inherent risks in our business.I am embarrassed to admit that when I started we never wore gloves and were sticking dirty needles in the bench seat cushion. In any event I'm going to start wearing our n-95's thanks.

The N95 is going to be an absolute must for treating these patients over the next while. Provided it is fit properly and the provider follows proper don/doff procedures the N95 and other isolation precautions should be adequate for the provider. One of the problems that still persists is the degree to which a standard nebulized treatment allows virus containing droplets to spread throughout the ambulance. That's an awful lot of surfaces to clean with a high likelihood something will be missed during the cleaning process. Any standard nebulized treatments will require the ambulance to go through a "deep clean" which will put the car out of service for 1-2 hours. This becomes a big problem in a service like the one I work for because some of the serviced communities have only one ambulance with the next closest car stationed more than an hour away.

[VentMedic]

Well I've started into the reasearch. So far it's actually looking like Terbutaline might be a better option for IV administration than Albuterol but still reserved for the more severe cases. Here are some of the studies I've come across so far.

Comparison of inhaled and intravenous terbutaline in acute severe asthma.

Continuous intravenous terbutaline for pediatric status asthmaticus

Continuous intravenous terbutaline infusions for adult patients with status asthmaticus.

Comparison of nebulized and intravenous terbutaline during exacerbations of pulmonary infection in patients with cystic fibrosis

The dose-response effects of terbutaline on the variability, approximate entropy and fractal dimension of heart rate and blood pressure

Not alot of compelling evidence out there. Terbutaline is still a decent medication but had its place in the spotlight in the late 70s and 80s where a couple of your studies are from. However, there have been several articles showing albuterol or salmeterol to be more effective.

One article you cited is inconculsive:

Since absorption of nebulized and subcutaneous terbutaline may be delayed or decreased during episodes of severe asthma, a preliminary trial of intravenous terbutaline was instituted in five adult patients with status asthmaticus. The terbutaline was administered as a bolus followed by a continuous infusion of 0.1-0.4 micrograms/kg/min. Although three patients may have received some improvement, the impact of intravenous terbutaline could not be distinguished from other concomitant therapy. All patients experienced tolerable adverse reactions. Further research to evaluate higher doses administered early in the hospital course and to determine receptor sensitivity needs to be conducted.

Again, there are going to be some factors to consider if this is to be used on flu patients. Unless they have bronchospasm from an underlying pulmonary hx, IV may not be as effective nor would a bronchodilator be always indicated with PNA or infiltrates with ARDS.

Also, if the patient is experiencing all the flu symptoms, you may have dehydration, hypovolemia, tachycardia and electrolyte imbalances to consider before introducing something IV such as Ventolin which is already noted for hypokalemia and known for Diabetes Mellitus exacerbations. Either medication can enhance the overall presenting situation. Thus, for flu patients, working with a filtered neb (or MDI) and the provider wearing the N95 mask may be a better alternative to target specific receptor sites and minimalize systemic side affects.

Now for the asthmatic patient, that might be beneficial. However, the literature has so far no proven the benefits across a broad range for even the countries where IV Ventolin is an option.

Here is a fairly recent (2002) study for pediatrics:

http://findarticles.com/p/articles/mi_m0689/is_7_51/ai_88999791/?tag=content;col1