Confusion on when to give Neb treatments and what to use..

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Rialaigh

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DEmedic said:
...and learn to identify a constricted capnography waveform, as opposed to a flat expiratory plateau. Using capnography can help you make those treatment decisions.
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Unfortunately there are very few services in my area that utilize nasal capnography.They found after putting them on the trucks at my current service that there were too many paramedics that did not want to change their practice and the nasal capnography was almost never utilized so they took it off the trucks to save the money.

Clare said:
Agree that heart failure can produce a wheeze that sounds like asthma, but I don't think asthma/COPD is that difficult to distinguish from heart failure, and I have yet to see a patient that has a history of both.
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Not sure about the demographics on the area you work in but we (on a daily basis) go to patients in very poor overall health with a history of CHF, MI, Afib, Stroke, Asthma, COPD, still currently smoke, Kidney failure....and I don't mean that patient has one of those, I mean patients who are currently being medicated for all those at once...
 
Ewok Jerky

Ewok Jerky

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Rialaigh said:
Not sure about the demographics on the area you work in but we (on a daily basis) go to patients in very poor overall health with a history of CHF, MI, Afib, Stroke, Asthma, COPD, still currently smoke, Kidney failure....and I don't mean that patient has one of those, I mean patients who are currently being medicated for all those at once...
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Pretty sure she is not in the US (NZ maybe?) so that's your answer right there.
 
YoungMedic

YoungMedic

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Comes down to getting great pt history and doing detailed assessments.
Lung sounds are a must
My system is huge on capnography as well as CPAP!!
Being able to do a Neb treamtment while having CPAP on has shown the best results for me.
 
DrParasite

DrParasite

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Rialaigh said:
Unfortunately there are very few services in my area that utilize nasal capnography.They found after putting them on the trucks at my current service that there were too many paramedics that did not want to change their practice and the nasal capnography was almost never utilized so they took it off the trucks to save the money.
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where in the carolinas do you work? we are pushing it pretty hard, an our medical director wanted capnography on every respiratory patient (which caused my ops director's head to explode, because those things are more expensive than a nasal cannula, but still).

Capnography is awesome, if you see the shark fin, give albuterol, if you don't, but you hear wheezing, consider cpap. atrovent might help, but I think it will work better on those pnemonia patient's who have increased secretions rather than the run of the mill asthmatic.
 
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rescue1

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Rialaigh said:
I think an important topic to bring up that has not been mentioned yet is the importance of identifying when NOT to give Albuterol/Atrovent.

Different studies show that a fairly significant portion of our heart failure patients with difficulty breathing can have cardiac wheezing or cardiac "asthma". Ive seen numbers range from less than 10% to almost a third of heart failure patients with start of pulmonary edema. Having seen the results of multiple patients receiving Albuterol or Atrovent when not properly differentially diagnosed and seeing the outcome of severe tachycardia, hypertension, and ultimately fairly rapid flash pulmonary edema almost always resulting in a fairly emergent RSI. I would put as much thought and effort into being able to properly identify your highly likely or suspected CHF patients and the source of the breathing problem before throwing a neb on everyone with wheezing. I think of all the medications we carry on most ambulance services this combination of meds, in the high frequency that they are given, are an area in which we actually do a substantial amount of harm to our patient population by misusing these drugs. More so than many of the other medications we carry.


Short Version - Get really really good at identifying your lung sounds in all lung fields, and know how to ask all the right questions to be sure with a high level of certainty that the patient your about to give a breathing treatment to is not suffering from acute CHF.
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I've read that the danger of administering albuterol to heart failure is often overstated, though poorly studied. I'm not sure if anyone has any more information on this.

Example:

http://www.medscape.com/viewarticle/738536
 
Medic Tim

Medic Tim

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Anyone else use pulmicort nebs.
I am a big fan of MDIs. My last service had them and nebs. My current only has nebs.... I miss having the option.
 
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Louis Sabat

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Try this to understand it better, research the 2 drugs on google, then see how the bodies mediators figure in that would be cyclic AMP and Cyclic GMP as it relates to the respiratory system
 
FltMedicRob

FltMedicRob

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I'm a big fan of duo-neb when giving a breathing treatment. One thing that I'm surprised hasn't been mentioned here yet..... Solumedrol. Our protocols say that if you give a duo you give the Solumedrol with it.
 
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46Young

Level 25 EMS Wizard
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Rialaigh said:
I think an important topic to bring up that has not been mentioned yet is the importance of identifying when NOT to give Albuterol/Atrovent.

Different studies show that a fairly significant portion of our heart failure patients with difficulty breathing can have cardiac wheezing or cardiac "asthma". Ive seen numbers range from less than 10% to almost a third of heart failure patients with start of pulmonary edema. Having seen the results of multiple patients receiving Albuterol or Atrovent when not properly differentially diagnosed and seeing the outcome of severe tachycardia, hypertension, and ultimately fairly rapid flash pulmonary edema almost always resulting in a fairly emergent RSI. I would put as much thought and effort into being able to properly identify your highly likely or suspected CHF patients and the source of the breathing problem before throwing a neb on everyone with wheezing. I think of all the medications we carry on most ambulance services this combination of meds, in the high frequency that they are given, are an area in which we actually do a substantial amount of harm to our patient population by misusing these drugs. More so than many of the other medications we carry.


Short Version - Get really really good at identifying your lung sounds in all lung fields, and know how to ask all the right questions to be sure with a high level of certainty that the patient your about to give a breathing treatment to is not suffering from acute CHF.
Click to expand...

Atelactasis/surfactant washout from pulmonary edema can cause the wheezes. If the ETCO2 waveform shows no significant loss of plateau (uneven alveolar emptying), and there is decent air movement, then a neb isn't going to help that patient. If you can easily hear rales, you probably have decent air movement, just food for thought. I see a fair amount of patients that have both COPD and CHF in their history. An in-line neb with CPAP and nitrates is a good option if there is both suspected cardiogenic pulmonary edema and some evidence of bronchoconstriction. We go with a duoneb typically.
 
NomadicMedic

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46Young said:
An in-line neb with CPAP and nitrates is a good option if there is both suspected cardiogenic pulmonary edema and some evidence of bronchoconstriction.
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This is usually my plan of action. Fix what you can fix and repeat your assessment to determine which pathway to continue down.
 
U

Uclabruin103

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rescue1 said:
I've read that the danger of administering albuterol to heart failure is often overstated, though poorly studied. I'm not sure if anyone has any more information on this.

Example:

http://www.medscape.com/viewarticle/738536
Click to expand...

I've worked in one county that said if wheezing in the situation of cardiac respiratory, then give albuterol with nitrates, cpap, etc. Then in another county it's only have stabilization of patient condition and with a base order. Clearly our medical directors differ in their line of thinking.

What are some of the differential questions that you all ask when you have the comorbidities of COPD, asthma, and CHF.
 
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