COPD?

[als_medic_uk]

Neither of those links you included mentioned an abnormally high mortality rate when using inhaled furosemide at 2mg/Kg. I was curious as to where that data was obtained certainly not the BPJ. May I point out there is a difference between relieving the feeling of the issue at cause and alternating the physiology. I merely stated what has been shown in numerous research examples. That when inhaled, a COPD patient may show relief from the feeling of dyspnoea. It also improves bronchodilation which in turn is beneficial to the patient. Maybe it isn’t a convenient pre-hospital medication; however, the context was regarding the treatment of COPD with Furosemide.

As for the use of spirometry, in a patient with dyspnoea, I find that not only futile but also bizarrely interdictory to the patient’s well-being.

I understand your issues, but I think your data, and medical knowledge is rather fundamental when it comes to the mechanisms of drugs, not being derogatory.

Regards.

[VentMedic]

als_medic_uk,

Neither of those links you included mentioned an abnormally high mortality rate when using inhaled furosemide at 2mg/Kg.

So, what data are you basing your information on?

High mortality rate?

Pulmonary Function Testing is done in the hospital setting to determine medication effectiveness. That is how the information is gathered to publish all of the articles you see in the journals about medications that affect the pulmonary system. From the data published, and yes there are more than the 2 articles I mentioned, and from experience, I have not found furosemide to be effective enough by itself to be routinely used. When we did try furosemide a few years ago, it was in conjunction with other medications and therapies. Furosemide may have to be reformulated as did tobramycin(TOBI) for inhalation, for the pulmonary system to accept it more readily. The factors I mentioned in the previous post also skew results in the ER. And, please don't confuse simple ER spirometry with the PFTs done with calibrated data collecting equipment from a Pulmonary Lab by a trained professional, not meaning to be derogatory of course.

I understand your issues, but I think your data, and medical knowledge is rather fundamental when it comes to the mechanisms of drugs, not being derogatory.

The 2 articles I linked to are to inform you what we use nebulized furosemide (and other meds) for off label in the US, in case, some pre-hospital workers do see it here. Nebulized furosemide is not used for COPD at this time in the US. We have various P&Ps that must be adhered to for off label medication use. There may be some facilities that are trialing it for research to publish but that will be in a more controlled setting. If the manufacturer offers us a grant to do some controlled Pulmonary Function Testing, maybe our hospital will get an article published also. I have be doing this long enough to "make" the data work for whoever wants results. If you have been in the medical profession for any length of time, you should be familiar with "reading the literature" and how the data is collected for results.

[wrenEMT]

The only reason I would have seen to use lasix during or after the SVN tx would be to take fluid off the lungs, but I have only seen that with pts that have a hx of CHF. They have the COPD because of the CHF, but I don't know if it would have been a bad idea to try 40 mg of Lasix IV as well. They might have used lasix in correlation of the BiPAP. I don't know I wasn't there to see the pt but you painted a good picture of the pts distress..

Either way I think you did a fine job with this patient. You did what you could per protocols for straight COPD pt with no hx of CHF. I would have done the same thing.

[firefighter523]

Ventmedic wrote:

"Furosemide might be seen nebulized in the neonate more commonly."

Why would you give a neonate a terotogen??

[VentMedic]

Furosemide, Lasix; loop diuretic

Neonates and furosemide:

Inhaled furosemide 1 and 2 mg/kg has improved pulmonary function in preterm neonates with BPD as shown by some studies. It is also used for TTN by either oral or nebulized administration. We use it periodically via nebulizer on specific cases in the NICU.

Infants have similar indications for oral, IV and nebulized furosemide as the adult population, CHF, liver and renal diseases where a loop diuretic might be indicated.

However, I doubt if paramedics in the US would be able to do off-label administration such as nebulized lasix to anyone, adult or neonate. They might be able to do this if they worked on a specialty transport team for a children's hospital.

[goofymedc8]

It sounds as though you covered all the bases with this pt. With the yellow sputum production, and I think some of us (myself included), may tend to forget that Chronic Bronchitis is also considered COPD. However, you're not incorrect to suspect pneumonia, either. That really doesn't change the treatment of this pt. 100% O2; IVx2 if you can, but one will do; Med Neb with Alb/Atrovent (My service doesn't carry Atrovent, so I double up on the Albuterol and make a continuous med neb); cardiac monitoring; VS every 5minutes. and 125mg SIVP Solu-Medrol. By the time you get to the ER that will kick in and reduce the inflammation in the lower airways. One thing I'd look for in my assessments is any pedal edema outside what may be normal for this pt; JVD; and any degree of orthopnea as well. Generally, pt's with COPD will eventually develop CHF; Cor Pulmonale (Right-sided heart failure). IF they have the hx of CHF, pushing the Lasix would probably figure in my treatment too. You did everything I would have...

[firefighter523]

Goofy, Maybe I am not understanding why you say that pts with COPD will develope CHF. I understand what you are saying about cor pulmonale, but I wouldn't think right sided HF would manifest in the lungs. Left sided HF causes right sided HF, not the opposite. Maybe a doc could step in on this and give us a little more information. I would like to know, what came first the chicken or the egg. COPD/CHF

[goofymedc8]

I guess I should've clarified a bit...I've seen a higher instance of long term COPDers that can develop CHF. Perhaps this is a tertiary process as a result of the Cor Pulmonale. I'm currently going back through ye old medic book to make certain I'm not too far off base. But it seems somewhat logical to me that over time Cor Pulmonale can also eventually lead to left HF due to the seemingly chronic reduction of the pump's ability to move fluid. I would welcome wisdom from the doc on this as well. I'm always willing to learn, refresh, and broaden my knowledge. I'm not perfect and the day I believe I am is the day I need to find another career.

Woohoo!!

[Doczilla]

The typical prehospital patient: obese chain-smoking hypertensive type II diabetic vasculopath with CHF. Nobody around here can seem to have any less than 4 of these concurrently.

COPD and CHF are separate entities that tend to run in the same circles for several reasons. The biggest reason is because of the same risk factor: smoking. Our hard core COPD patients tend to be dedicated (or until their most recent MI) smokers, which increases the risks of vascular disease, MI, and hypertension, all of which lead to CHF.

COPD can lead to pumonary hypertension and right-sided heart failure. This is more likely to result in atrial arrhythmia (a-fib) than pulmonary edema. It is also true that the most common cause of right sided heart failure is left sided heart failure, the latter of which would cause the fluid overload in the lungs.

To complicate things even further, fluid overload and left sided heart failure may cause bronchospasm, sometimes referred to as "cardiac asthma". This clouds the clinical picture significantly if you have a patient with a history of cardiovascular disease who has never smoked and is now wheezing.

With regard to nebulizing lasix for dyspnea, it's not that well studied or understood. It's far from standard practice on this side of the pond. For terminal cancer patients with dyspnea or neonates with bronchopulmonary dysplasia, this might be worth trying (though evidence here is still pretty thin), but I have yet to see any studies of decent quality demonstrating its benefit in garden-variety CHF or COPD. I'll call this one voodoo until some better evidence comes along.

'zilla

[tniuqs]

lady needs to QUIT SMOKING -

HUH ?? OK then this is ALL balderdash and nonsence ! Everyone knows that SMOKING has been known to be GOOD for YOU, and we ALL need to promote this Actively.

Hey I am working on a cushy home care job in my retirement as an RRT, PLEASE Stop raining on my Parade would you ..... Your scaring my potential patients.

Cheers: A very informative thread and good exchange of ideas without getting silly.

On another topic: I am starting an ETOH nebulizer BAR, any interested investors out there inquiries welcome ... te he.