new paramedic - question on breathing treatments

[speedygodzilla]

Thanks for the clarification.

Sometimes I we call the combination of A/A Duoneb, but I would not document it as such as we don't carry Duoneb.

It is nice to know Atrovent is no longer contraindicated with a peanut allergy. Learning all the time. How about soy allergy? It seems I need to pull out the sheet that comes with the drugs as they are delivered to our department, as I would assume they are up to date.

Edited April 2, 2010 by speedygodzilla

[VentMedic]

It is nice to know Atrovent is no longer contraindicated with a peanut allergy. Learning all the time. How about soy allergy? It seems I need to pull out the sheet that comes with the drugs as they are delivered to our department, as I would assume they are up to date.

Again Atrovent liquid did not present an allergy issue for those allergic to peanuts or soy.

The lecithin base used in the CFC propellant MDIs of Atrovent and Combivent (which is Albuterol/Atrovent combo) did present a potential problem. Atrovent is now HFA and the lecithin is no longer used in the product. Unfortunately Combivent still has not been able to reformulate so it still is CFC with lecithin making it a problem for those with peanut or soy allegies.

New Atrovent HFA MDI insert: Note there is no mention of peanut/soy allergies.

http://bidocs.boehringer-ingelheim.com/BIWebAccess/ViewServlet.ser?docBase=renetnt&folderPath=/Prescribing+Information/PIs/Atrovent+HFA/10003001_US_1.pdf

general pt info

http://fdb.rxlist.com/drugs/drug-93239-Atrovent+HFA+Inhl.aspx?drugid=93239&drugname=Atrovent+HFA+Inhl&source=0

The link I posted earlier.

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

Note the Combivent information.

There have been numerous changes to Respiratory medications during the past 3 years to be in compliance with the 1987 Montreal Protocol (treaty) which is why I posted the earlier links. In fact, just about every MDI had to reformulate. Combivent has been granted a stay of termination for now as it attempts to produce an HFA product. There is a chance that none of the MDIs are as they were presented in your Paramedic text book. I am actually still seeing EMS information with Bronkosol listed as a frontline med.

Edited April 2, 2010 by VentMedic

[firedoc5]

I'm a little sleepy and I might have missed some info and I might be repeating myself.

Let's get back to the basics. Remember, Asthma, COPD, etc. do NOT need high flow O2. 1-2 L/min with a nasal canula. You can increase it up to 3L/min if the patient can tolerate it. The pt. must be observed at all times. Be sure that they had used their own rescue inhaler. Some may have acute SOB and didn't or couldn't use their own inhaler. If not by all means try their inhaler first. If they use OTC Primatine, let them try it but discourage them from using it anymore and see about Combavent. If they have and had not responded to it....just listened to Vent and you'll do fine.

One thing that may have been mentioned but just in case I'll re-empaphize it. If you have a long response time to a hospital and they are in COPD with CHF or Paracardial Tampanade, go with a diaretic, such as Lasix. If you have the ability insert a foley, but not absolutely needed, just easier. I know that might not be standard practice to do so, but when I was in the field that's one thing we could do.

If still SOB with cyanosis go ahead and increase O2, but be prepared to tube. I've had to do that on a few occassions. It's not recommended, just a last ditch effort.

Edited April 2, 2010 by firedoc5

[chbare]

Actually, COPD patients often do require high flow modalities. Remember, high FiO2 and high flow are profoundly different concepts. Additionally, a NRM at 15 LPM is NOT a high flow modality. Simply stated, a high flow modality must meet or exceed the patient's flow requirements. A simplified way to view it is the following;

Say I have a Vt of 500 and I am having some respiratory distress and am breathing at say 34 times a minute. That gives me a minute ventilation of 17 litres. Will a NRM at 15 LPM meet my inspiratory flow requirement? That is not even throwing in other concepts that can alter the flow requirement.

In addition, a loop diuretic is not a cure all for every patient with CHF. We need to be very careful about giving loop diuretics in the pre-hospital environment. In addition, other modalities should be considered.

Take care,

chbare.

EDIT: added an '.

Edited April 3, 2010 by chbare

[Kiwiology]

Not all dyspnea patients need or will be helped by a bronchodilator ... Remember, we do not have beta adrenergic receptors in our alveoli, contrary to what many people believe. Rather, the decision to use a dilator should be based on good evidence pointing to bronchospasm. Unfortunately, albuterol is not the scrubbing bubbles all purpose lung cleaner and general purpose respiratory cure all that people often make it out to be.

Hmm, can we nebulise dish soap then, will that clean that nasty icky puss and crap out of our patients lungs?

You touch on a very good point; not everybody needs salbutamol and like oxygen, IV fluid and one or two other things out there in the realm of prehospital medicine it is routinely dished out either a) to people who do not require it or in concentrations above what is required.

I've known people to take upwards of 5 minutes to give an asthmatic patient some salbutamol because he had a temperature and the Technician was unsure if he could give nebules to a patient with a chest infection.

Not to diss the guy for not knowing but *facepalm, know thy medication!

Let's get back to the basics. Remember, Asthma, COPD, etc. do NOT need high flow O2.

Does anybody NEED "high flow" O2 (in the context of ambulance practice to mean fifteen litres on a non rebreather mask)?

If you have a long response time to a hospital and they are in COPD with CHF or Paracardial Tampanade, go with a diaretic, such as Lasix. If you have the ability insert a foley, but not absolutely needed, just easier. I know that might not be standard practice to do so, but when I was in the field that's one thing we could do.

If still SOB with cyanosis go ahead and increase O2, but be prepared to tube. I've had to do that on a few occassions. It's not recommended, just a last ditch effort.

Increasing O2 probably won't help for oxygenation and ventilation are not the same thing. You can crank that O2 regulator off the meter and cram a truck load of O2 down thier throat but if it's not able to reach the brain and vital organs it won't do much.

If anything it may be harmful; it's been drilled into us here in New Zealand that an asthmatic patient who requires manual ventilation should not be bagged more than six times a minute to avoid dynamic hyperinflation. Apparently there have been a few sparky people out there bagging the snot out of respiratory arrested asthmatics.

Now if there's a bigger controvesy out there than prehospital frusemide I'm yet to find it. I don't think it should be part of the standard kit of an Ambulance Officer and recent grumblings here in New Zealand show it's probably being slated for removal.

Actually, COPD patients often do require high flow modalities. Remember, high FiO2 and high flow are profoundly different concepts. Additionally, a NRM at 15 LPM is NOT a high flow modality. Simply stated, a high flow modality must meet or exceed the patient's flow requirements.

So how do you ensure a high FiO2 above what I can deliver with my ubiquidos black and white cylinder of oxygen?

[chbare]

In one sense, there are cases when we do administer a substance that works in a similar way to detergent. The most common scenario is administering surfactant in the setting of surfactant deficiency syndrome.

I am not sure I understand the FiO2 question. Clearly, it is not possible to deliver more than an FiO2 of 1.0; however, my point being there is a profound difference between flow and FiO2. For example, I can place somebody on mechanical ventilation with a flow of 60 LPM yet only have an FiO2 of 0.21. Likewise, I can breath a gas mix under several atmospheres of pressure that utilises a sub-atmospheric FiO2, yet have a partial pressure of oxygen can be higher than what is encountered at sea level. Therefore, the concepts of FiO2, partial pressure, and flow are quite different.

Take care,

chbare.

[VentMedic]

For example, I can place somebody on mechanical ventilation with a flow of 60 LPM yet only have an FiO2 of 0.21.

Christopher "Superman" Reeve is a good example. He was on the LTV ventilator delivering a flow to meet his repiratory needs and most of the time it was on an FiO2 of 0.21.

I also find recipes of "give 2 L NC for this" and "give 4 L NC" for that to be laughable. It just demonstrates how lacking EMS education is when it comes to understanding minute volume (MV) even though I believe EMT-Bs have it in their text books. Could it be the "instructors" don't understand it well enough to explain the application of MV and some may think it is just some academic BS tossed in for the hell of it?

A person could be getting more FiO2 on 2 L NC than someone on 4 or 6 L NC depending on their respiratory rate and minute volume.

For more high flow information, I just typed this on the "Threw up and can't breathe" thread.

http://www.emtcity.com/index.php/topic/18108-threw-up-and-cant-breathe/page__gopid__239490&

If the ABG was drawn on a NRBM, we would use 0.85 or 0.90 as the FiO2 for the PaO2/FiO2 calculation. That gives a PF ratio of 67 which is very, very serious. Some should take not that the SpO2 was mentioned at 88% which is possible but in this situation, the SpO2 does not reflect the seriousness of this patient.

If this patient is on a humidified high flow system delivering an FiO2 of 1.0, that may be difficult to transfer. BTW, if you see a standard humidifier running of a standard flow meter (not one capable of 70+ L/M) that device will not be delivering an FiO2 of 1.0 to an adult breathing at a RR of 34. It would take at least two ("Dual") humidifiers to get a little closer to an FiO2 of 1.0. The standard humidifier with an aerosol mask, even though it may say 100% on the adjustment, will probably be delivering an FiO2 of around 0.60 for an adult with a high respiratory rate and MV.

Now, how to deliver high flow O2 during transport without using a mechanical ventilator for CPAP/BiLevel....

The O2 supply system would have to be addressed since many of the devices require a flow meter capable of delivering at least 70 L/m. Some of the easier and more comfortable high flow devices such as the high flow NC can deliver 30 - 40 L/m but at this time I don't believe any of them are battery powered and the heating element must have keep the humidifier delivering at 37 degrees and a relative humidity of 44 mg/L. The MistyOx or TheraMist can deliver high flows but require a high flow meter to power them at 30 - 40 L/min. The Oxymask can be considered high flow must the standard flow meter may need to be ran at flush. In the hospital I have used a high flow nasal cannula at 30 L/m along with the Oxymask at well over 15 L/M to oxygenate a patient with a good respiratory drive preintubation. The RSI is done very quickly since bagging a patient who has progressing ARDS is very difficult with the standard self inflating BVM. I would probaby suggest taking something like a Jackson Rees bag along with the self inflating BVM.

That is a good thread since several here probably want to be "CCEMT-Ps" and believe the 80 hours class is more than enough to do CCT. Few get past the skills to understand the whys and hows of the patient. Sometimes the words "critical thinking" are not fully understood.

[firedoc5]

In my earlier post I was not meaning the every day COPD/CHF pt. I should have clarified that in the post. I was refering to the pt. in a dire situation. I just gave examples of what can be done. It is up to Medical Control and the Lead Medic be in constant contact. I was going with the orders I have been given by Medical Control, some seemed just not right at the time. But each time after getting to the hosp. I would sit down with whoever was giving the orders and them explain them to me. I never liked being told to purposely knock out someone's breathing drive and tube them. But you are talking about the early 80's to the early '90's. And yes, I've used a non-RBM at 12-15 L/min on COPD pts. Especially those with cyanosis. You just have to monitor their breathing more closely than your average pt.

I hope I haven't confused anyone. But like I stressed before, go with the basics at first then progress from there.

[VentMedic]

I never liked being told to purposely knock out someone's breathing drive and tube them. But you are talking about the early 80's to the early '90's. And yes, I've used a non-RBM at 12-15 L/min on COPD pts. Especially those with cyanosis. You just have to monitor their breathing more closely than your average pt.

I hope I haven't confused anyone. But like I stressed before, go with the basics at first then progress from there.

If you "knocked out" someone's respiratory drive with a NRBM in just a few minutes, they needed a tube. For their CO2 to have risen that high indicates they may have a significant disease process.

I'm going to refer to Jeff Whitnack for more details and literature references.

http://home.pacbell.net/whitnack/Why_the_Hypoxic_Drive_Theory_Sucks_Wind.htm.6306

I do find this quote from him quite amusing.

Where are the episodes on "Murder She Wrote", as then home oxygen would be the perfect murder weapon (the evidence would disappear after the heinous crime) for any greedy relatives of a CO2 retainer?

Several of my home O2 patients play with their O2. Although a concentrator is generally limited to 6 l/m which might be the equivalent of 3 depending on the maintenance of the machine. But, in the hospital I catch them cranking their own O2 up all the time and usually it doesn't cause must damage except for screwing up my charting and causing a nurse to freak out who was trained strictly by the "hypoxic drive theory".

I have also told a story a few times on the forums about a COPD patient who wanted to end it all and thought he found the perfect way when he over heard a doctor, RN and Paramedic talking about the "horrors of a NRBM" with a COPD patient. He managed to find on before he left the hospital. After getting his affairs in order, he sat up a couple of H tanks which were still used in homecare at that time. He settled down in his easy chair with the NRB running at 12 liters and fell asleep. In the morning he work up refreshed and better than ever. He decided this was a sign and that he should rethink his suicide plans. So, with the NRBM still blowing out O2 around his neck on his O2 saturated PJs, he lit a cigarette to give his life more thought... The End.

However, for any patient who does not need more O2 than necessary, I do not recommend high FiO2s to be used. This especially includes post op patients who come out of PACU on 2 - 4 L NC as a standing order. For any patient displaying signs of respiratory distress, they will get what it takes both by O2 and other meds to make them comfortable. Often the respiratory issues are directly related to another system such as circulatory and not necessary a pulmonary problem.

[firedoc5]

There was at least twice we were instructed to use a BVM, high flow O2, and to hyperventilate. BTW, it was the same doc. He was older and would walk around the hosp. doing rounds smoking. He had an ash try on the cart holding the charts. But he gave us those orders. I think he was trying to put them in an "induced coma" so we could tube without numbing the throat. Like I said, I hated it when we got those orders. The only other time we had a pt. that needed to be tubed, very evident CHF, but we could not relax his gag reflex, no matter what we did. I wanted to try some IV Valium or MS, but the doc on the radio said no. "Hyperventilate a little more and gag reflex will relax". I argued with that doc later. Thought I was going to get wrote up or something.

BTW: Neither of those docs worked ER but a few more times after that. THEN we started getting actual ER docs through an agency and not have local docs rotate through.