CHF and albuterol

[fakingpatience]

I have a question for y'all about giving albuterol to a patient. I know that the indication for albuterol is wheezes. I also heard that CHF is a contraindication for albuterol because the broncodialators in the med will allow more fluids into the lungs, increasing the difficulty breathing (Someone correct me if this explication is wrong). So what do you do for the patient who has a hx of both asthma/ COPD and CHF and has diminished lung sounds? Would you give the albuterol/ duoneb until you can hear better lung sounds, and base your further treatment off of that? What if the cause of the SOB is CHF and you have now made it worse? CPAP?

Sorry if the question above is convoluted, I was wondering because I had a pt recently who had hx of CHF, but no other lung hx, and was diminished on the L side, and my partner gave her a duo neb treatment, even though she was stating at 98% RA, because her RR was about 30 (no other signs of SOB)

When I was initially certified to give neb albuterol, I never learned that CHF was a contraindication for it, and it scares me that I didn't learn all the information about a drug I was certified to give. If y'all have any good resources for this info, that would be great, but I would also like to discuss it here, I always learned best from class discussions

[FireMedicChick164]

This same question popped up on the JEMS website too. I have posted the link below so you can look at that too.

http://connect.jems.com/forum/topics/albuterolchf-1?xg_source=activity

In NY where I practice albuterol is indicated for asthma and COPD. I do remember our instructors telling us that we shouldn't use it for CHF patients. It can make their condition much worse. I always try to get a thorough history before I give any meds and the few CHF patients I have seen we have just given O2 and put on a cardic monitor. Our closest hospital is less than 10 minutes away.

I have a question for y'all about giving albuterol to a patient. I know that the indication for albuterol is wheezes. I also heard that CHF is a contraindication for albuterol because the broncodialators in the med will allow more fluids into the lungs, increasing the difficulty breathing (Someone correct me if this explication is wrong). So what do you do for the patient who has a hx of both asthma/ COPD and CHF and has diminished lung sounds? Would you give the albuterol/ duoneb until you can hear better lung sounds, and base your further treatment off of that? What if the cause of the SOB is CHF and you have now made it worse? CPAP?

Sorry if the question above is convoluted, I was wondering because I had a pt recently who had hx of CHF, but no other lung hx, and was diminished on the L side, and my partner gave her a duo neb treatment, even though she was stating at 98% RA, because her RR was about 30 (no other signs of SOB)

When I was initially certified to give neb albuterol, I never learned that CHF was a contraindication for it, and it scares me that I didn't learn all the information about a drug I was certified to give. If y'all have any good resources for this info, that would be great, but I would also like to discuss it here, I always learned best from class discussions

[chbare]

Let me turn this around on you in the name of thinking this through?

How does albuterol increase the amount of fluid in the lungs and what mechanism is responsible? "I was told so" is an invalid answer as I expect and hope my students verify the dogma that I spew at them. If I am lucky, they push hard to understand and perhaps get one over on me.

What are the causes of diminished lung sounds and are any of these causes treated by albuterol administration? You will need to research the answers. Furthermore, when giving albuterol for "wheezing," is there an underlying pathology that we are looking to find that will cause said wheezing?

After all this, we can discuss your partners decision making and the rationale he/she used to justify the decision to treat. My apologies if this comes off as a "non answer."

I hope to read and learn from the fruit of your research.

Take care,

chbare.

[PCP]

Let me turn this around on you in the name of thinking this through?

How does albuterol increase the amount of fluid in the lungs and what mechanism is responsible? "I was told so" is an invalid answer as I expect and hope my students verify the dogma that I spew at them. If I am lucky, they push hard to understand and perhaps get one over on me.

What are the causes of diminished lung sounds and are any of these causes treated by albuterol administration? You will need to research the answers. Furthermore, when giving albuterol for "wheezing," is there an underlying pathology that we are looking to find that will cause said wheezing?

After all this, we can discuss your partners decision making and the rationale he/she used to justify the decision to treat. My apologies if this comes off as a "non answer."

I hope to read and learn from the fruit of your research.

Take care,

chbare.

Okay, I am going to take a crack at this question. Albuterol is a brochodialater and has two effects. One is the the B1 effect which increases heart rate and blood pressure and the B2 effects will open up the bronchiols which will increase the pulmonary edema. Wheezing in a CHF patient are a sign of the lungs' protective mechanisms, since bronchioles constrict in an attempt to keep additional fluid from entering the lungs. So by giving the pt. ventolin it will increase the cardiac output and open up the bronchiols allow more fluid to pool in the bases of the lungs.

diminished lung sounds are caused by pulmonary edema which is caused by the heart's reduced stroke volume. The heart's reduced stroke volume causes an overload of fluid in the body's other tissues. This presents as edema, which can be pulmonary, peripheral, sacral, or ascitic.

From my understanding is that when treating someone with CHF is to apply high flow O2 @ 15lpm don't have them walk to the stretcher as this can increase the laboured breathing so use the slider board and slide them over to the main cot. Have them sitting up with their legs raised as this will promote venous pooling, thus decreasing preload.

Great discussion!

Brian

[chbare]

I'm not sure I understand or agree with the "additional" fluid analogy. Does strong evidence (literature) suggest this as a harmful mechanism of albuterol therapy (salbutamol)?

Take care,

chbare.

[PCP]

I'm not sure I understand or agree with the "additional" fluid analogy. Does strong evidence (literature) suggest this as a harmful mechanism of albuterol therapy (salbutamol)?

Take care,

chbare.

Hi chbare,

No it does not, but I am going to take a look and find out. I was attempting to answer the question based on what I know of salbutamol and CHF. I was assuming based on the B1 and B2 effects of salbutamol that it would increase the fluid build up in the bases of the lungs.

Sorry for attempting to answer the question without researching what effects salbutamol would have on a CHF patient. As I know on the website we like to keep things straight forward and try not post incorrect information.

Take care,

Brian

[DwayneEMTP]

Hi chbare,

No it does not, but I am going to take a look and find out. I was attempting to answer the question based on what I know of salbutamol and CHF. I was assuming based on the B1 and B2 effects of salbutamol that it would increase the fluid build up in the bases of the lungs.

Sorry for attempting to answer the question without researching what effects salbutamol would have on a CHF patient. As I know on the website we like to keep things straight forward and try not post incorrect information.

Take care,

Brian

Good for you for stepping up Brian! A private tutoring session with chbare is worth much more than the time spent here! But I disagree with your assertion that you should have researched before answering. Though he did say that folks would need to research the answers to his questions, trying to work these problems through with the information in your head, in my opinion, is ALWAYS the right thing to do first! This is how you build logic trees, it's also how you allow your brain to learn to function as if you were on a call. Autonomous and without Google.

So, if you're going to post something claiming that it is fact, then you certainly should site the reasons that you claim it to be so, otherwise there is no shame, in fact you should be proud, of working the problems out with only the supplies that nature put on above your shoulders.

Excellent responses so far. I'm not going to participate in the answer at this point, as you're doing fine without my goofy help. I just wanted to jump in quick and make the point above.

As you were.... :-)

Dwayne

[PCP]

I spoke to a friend this morning who is a ER nurse and asked him about giving Salbutamol to a CHF patient as well as talked a bit about what is going on with a CHF patient. From my understanding now is that giving a CHF patient Salbutamol is a good thing, as it opens up the bronchioles which will then allow for better oxygen exchange in the lungs. I also learned that a patient experiencing pulmonary edema from CHF is due to left heart failure. when the left ventrical decreases in cardiac output it causes the fluid to back up into the lungs. I may be wrong, but when a pt. has CHF along with pulmonary edema, Starling law is no longer affective. Taht is the ventrical is unable to stretch to its maximum compacity, which in turn causes the preload to be affected.

In my understanding now of CHF and giving a pt. Salbutamol is that it will not cause the patient to experience an increase of fluid in there lungs, but will indeed help them, due to dilating the bronchioles helping the patient get better oxygen exchange.

I believe the mechanism that causes the pulmonary edema is a circulatory issue due to the left heart failure. Part of what I was taught in school was that at times we may need to bag a patient with CHF due to the poor oxygen exchange in the lungs and pending respiratory failure.

I have never seen it, but I know of paramedics that have had to bag a patient that where a foamy substance is coming out of the patient's mouth due to the overload of fluid in the lungs. Our objective is to bag this patient and attempt to push the foamy substance and the fluid out of the lungs and back into the circulatory system, so that the patient will be able to have better oxygen exchange, which then increase their respiratory efforts, hopefully keep them from going into respiratory arrest.

Well there it is my second attempt of trying to figure this problem out and hopefully answer some of the questions asked.

Thanks for all that have participated in this discussion as I find discussions like this very helpful in understanding and learning more about certain complications that a I need to deal with as a paramedic.

[crotchitymedic1986]

I do not believe Albuterol is contraindicated, but Atrovent is.

[tniuqs]

I spoke to a friend this morning who is a ER nurse and asked him about giving Salbutamol to a CHF patient as well as talked a bit about what is going on with a CHF patient. From my understanding now is that giving a CHF patient Salbutamol is a good thing, as it opens up the bronchioles which will then allow for better oxygen exchange in the lungs. I also learned that a patient experiencing pulmonary edema from CHF is due to left heart failure. when the left ventrical decreases in cardiac output it causes the fluid to back up into the lungs. I may be wrong, but when a pt. has CHF along with pulmonary edema, Starling law is no longer affective. Taht is the ventrical is unable to stretch to its maximum compacity, which in turn causes the preload to be affected.

In my understanding now of CHF and giving a pt. Salbutamol is that it will not cause the patient to experience an increase of fluid in there lungs, but will indeed help them, due to dilating the bronchioles helping the patient get better oxygen exchange.

I believe the mechanism that causes the pulmonary edema is a circulatory issue due to the left heart failure. Part of what I was taught in school was that at times we may need to bag a patient with CHF due to the poor oxygen exchange in the lungs and pending respiratory failure.

I have never seen it, but I know of paramedics that have had to bag a patient that where a foamy substance is coming out of the patient's mouth due to the overload of fluid in the lungs. Our objective is to bag this patient and attempt to push the foamy substance and the fluid out of the lungs and back into the circulatory system, so that the patient will be able to have better oxygen exchange, which then increase their respiratory efforts, hopefully keep them from going into respiratory arrest.

Well there it is my second attempt of trying to figure this problem out and hopefully answer some of the questions asked.

Thanks for all that have participated in this discussion as I find discussions like this very helpful in understanding and learning more about certain complications that a I need to deal with as a paramedic.

PCP you may want to remember that the title "Paramedic" in the American website Emtcity is suggestive of an ACP or CCP where you reside, a bit of an anomaly on a world wide basis.

cheers