new paramedic - question on breathing treatments

[matt c]

hey guys, im a fairly new paramedic (about 5 months) and unfortunately i work at a private service right now. we do a lot of bls intercepts and nursing home emergencies. my question is this. i know you use albuterol in asthma, but are duonebs also indicated in people who have PNA with SOB? i also have heard many contradicting theories on whether or not to give a treatment for people with SOB from chf, supposedly a treatment can just worsen their fluid problem. well anyways any insight in this subject would be appreciated! thank you guys! ( and girls )

[JakeEMTP]

Hey Matt, welcome to the City!

Usually, if your pt. is having difficulty breathing enough to call 911 and has a hx of Asthma, I'll bypass the Albuterol and go directly to a duoneb of Albuterol and Ipatropium along with 125mg Solumedrol IV, depending of course on my assessment of the pt. But, Asthmatics know they have Asthma and are very aware of an onset of an attack. In most cases they have already used their meter dose inhaler w/o relief, that's why they called us. It doesn't make sense to give them more of something that isn't working.

With CHF pt.'s, I will avoid Albuterol like the plaque. You're correct in your assumption that they will get worse. The patient is basically drowning. What we need to do is get rid of the fluid somehow, not add to it. Pt.'s with CHF having a true respiratory distress crisis will need CPAP, and nitro for the hypertension, not a nebulized Albuterol treatment.

Sorry for the short response Matt, I have a meeting to go to.

Again, welcome to EMT City!

Take it away Ventmedic!

[VentMedic]

Take it away Ventmedic!

Thank you for that introduction Jake.

It is important to find out when the patient started using nebs/MDIs and what type. Some people are given MDIs at their GPs office but are not given any clear instruction about why or when. Thus, we now have very good medications that are under scrutiny due to fatal incidents when the problem is actually a lack of communication. The LABAs fall into this category unfortunately. It would be important to note if the patient is mistakenly using an LABAa as a SABA or rescue inhaler. I personally have seen at least 5 emergencies involving LABAs recently. One was from EMS who had the patient on a "Duoneb" while the patient was holding an empty Symbicort canister which their had just gotten a script for on previous day. The HR was 250+ but that was not known since the patient was not hooked up to a cardiac monitor until they reached the ED. Palp HR by radial was 80. The patient was also told by the Paramedics to take "another hit" off the LABA while they sat up a nebulizer. So the Paramedics has assumed the patient was holding a rescue inhaler (SABA) and did not check what med they had just told the patient to take. Rookie mistake or one of extreme carelessness that can be potentially fatal.

Here are some links for all the new meds out there. Note that Albuterol is not yet available by the generic name of "Albuterol" with the HFA formulation. If you see a generic canister of Albuterol (CFC propellant), check the expiration date. However, there are brand name "Albuterol" MDIs on the market.

SABAs

http://www.aaaai.org/patients/resources/medicationguide/saba.stm

LABAs

http://www.aaaai.org/patients/resources/medicationguide/bronchodilators.stm

Cromolyn and theophylline

http://www.aaaai.org/patients/resources/medicationguide/cromolin_theophylline.stm

Inhaled Corticosteroids (not Advair and Symbicort which contain a LABA)

http://www.aaaai.org/patients/resources/medicationguide/inhaled_corticosteroids.stm

Leukotriene Modifiers

http://www.aaaai.org/patients/resources/medicationguide/leukotriene_modifiers.stm

Immunomodulator

http://www.aaaai.org/patients/resources/medicationguide/immunomodulator_medications.stm

Also, many of the nasal sprays will have similar names as the MDIs including the corticosteriods and Atrovent (Ipratropium bromide) and can easily be confused at first glance.

http://www.aaaai.org/patients/resources/medicationguide/nasalmedication.stm

Sidenote: Duoneb may not be the name seen as often since the generic Albuterol/Ipatropium bromide is readily available now and a little cheaper.

Edited April 1, 2010 by VentMedic

[VentMedic]

Now to get a little more specific.

Albuterol is the cure all for everything or so it would seem. If you don't know what is going on in the chest, they get an Albuterol neb in hopes of sorting out the sounds left or that appear after the treatment.

Atrovent (Ipatropium Bromide) is generally more effective in COPD patients. However, since asthma can also fall into the broad category of COPD and the lung remodeling that occurs, Atrovent may also be a good med to use with the Albuterol.

For PNA, it depends on the history, type and site of the PNA as to whether Albuterol can be effective. Sometimes patients may have a bronchospasm present with the PNA and sometimes not. However, if a neb is given that is powered by O2 from a tank, the patient will probably rave about how good they feel just because of the extra O2. The extra flow may also enhance the intrinsic PEEP effect that may splint some of the airways. This is one of several reasons why I prefer a mouthpiece neb over the mask.

CHF is also controversial. If the patient has an underlying PNA or pre-existing lung disease which could also have been an initiating factor for the CHF, Albuterol or Albuturol/Atrovent may help but I would not delay initiating other therapy such as CPAP.

For pulmonary edema post operatively following lung surgery and early stages of ARDS, we have been conducting studies for Albuterol (Salbutamol studies in Canada). We have noticed some improvement with the Albuterol and not as much with the Atrovent (Ipatropium Bromide). But, there are many factors to consider with each patient.

[tcripp]

... have PNA with SOB?

PNA = pneumonia?

[JakeEMTP]

Thank you for that introduction Jake.

Ha! I always look to your expertise for assistance with respiratory questions. I just knew you could help our friend here!

[matt c]

thank you guys very helpful answers i really appreciate it..... i love this web site!

PNA = pneumonia?

yes PNA is short for pneumonia, or so ive been taught lol

[tcripp]

yes PNA is short for pneumonia, or so ive been taught lol

Thanks. Not all systems use the same abbreviations and that's not been one of mine. That one we are expected to spell out.

Actually, it would be great if everyone got in the habit of spelling out the word with their suggested abbreviation in the original post. Then, others can follow suit if they choose. That way, we are all on the same page. (i.e., ...pnuemonia (PNA)...)

Either that, or we create a page on this site with agreed to abbreviations/acronyms?

[JakeEMTP]

Actually, it would be great if everyone got in the habit of spelling out the word with their suggested abbreviation in the original post. Then, others can follow suit if they choose. That way, we are all on the same page. (i.e., ...pnuemonia (PNA)...)

Great idea. Might be something to put in the site rules, if anybody reads them when they join!

[tcripp]

Great idea. Might be something to put in the site rules, if anybody reads them when they join!

There are site rules?