# Xopenex in place of Albuterol for Suspected Cardiac Wheeze



## AeroClinician (Oct 15, 2012)

Is there any agency out there that has a protocol for xopenex in place of albuterol for a suspected cardiac wheeze?


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## DrankTheKoolaid (Oct 15, 2012)

No as cardiac asthma is not an indication for a beta adrenergic that will potentially worsen the patients  condition by further increasing the work of the heart. Ntg and cpap is what they need and the wheeze will correct itself


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## AeroClinician (Oct 15, 2012)

Corky said:


> No as cardiac asthma is not an indication for a beta adrenergic that will potentially worsen the patients  condition by further increasing the work of the heart. Ntg and cpap is what they need and the wheeze will correct itself



Here is the problem with treating a suspected cardiac wheeze immediately with nitro, cpap and possib. lasix -> Its because if you are wrong and it is not a cardiac wheeze, then you will dry out your patient and the condition will get worse. Because we cannot determine for sure it is a cardiac wheeze or non cardiac wheeze we must give a bronchodialator as a diagnostic tool first to confirm our suspections then switch off to CHF treatment for the confirmed cardiac wheeze. A good example is a patient that has Asthma and CHF presenting with wheezes. And it comes down to giving xopenex instead of albuterol because xopenex has less B1 effect with a good B2 effect.


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## usalsfyre (Oct 15, 2012)

Firehazmedic said:


> Here is the problem with treating a suspected cardiac wheeze immediately with nitro, cpap and possib. lasix -> Its because if you are wrong and it is not a cardiac wheeze, then you will dry out your patient and the condition will get worse. Because we cannot determine for sure it is a cardiac wheeze or non cardiac wheeze we must give a bronchodialator as a diagnostic tool first to confirm our suspections then switch off to CHF treatment for the confirmed cardiac wheeze. A good example is a patient that has Asthma and CHF presenting with wheezes. And it comes down to giving xopenex instead of albuterol because xopenex has less B1 effect with a good B2 effect.



Leave out the lasix and it's not really "drying out" a patient. Levalbuterol's price makes it an unrealistic choice for most of EM, let alone EMS. Finally, good history will usually narrow down your root cause.


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## AeroClinician (Oct 15, 2012)

usalsfyre said:


> Leave out the lasix and it's not really "drying out" a patient. Levalbuterol's price makes it an unrealistic choice for most of EM, let alone EMS. Finally, good history will usually narrow down your root cause.



But if price is not an issue because it is only on the truck for this single purpose then it really couldnt be that expensive to carry 1 dose per unit. I know what your talking about with looking for a history of sudden onset (cardiac wheeze) vs a slower onset (Non-cardiac wheeze). The problem is that some medics cannot be trusted to adequately decipher cardiac vs non-cardiac and they end up giving nitro to the non-cardiac wheeze and the patient ends up dying because the pt.s condition was so bad to begin with.


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## Sublime (Oct 15, 2012)

Is training your paramedics to differentiate acute asthma attacks from CHF exacerbation too much to ask?


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## AeroClinician (Oct 15, 2012)

Sublime said:


> Is training your paramedics to differentiate acute asthma attacks from CHF exacerbation too much to ask?



Its just too easy to be wrong in this situation and it is much better to use xopenex as a diagnostic tool first to confirm suspicions.


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## NYMedic828 (Oct 15, 2012)

Firehazmedic said:


> Here is the problem with treating a suspected cardiac wheeze immediately with nitro, cpap and possib. lasix -> Its because if you are wrong and it is not a cardiac wheeze, then you will dry out your patient and the condition will get worse. Because we cannot determine for sure it is a cardiac wheeze or non cardiac wheeze we must give a bronchodialator as a diagnostic tool first to confirm our suspections then switch off to CHF treatment for the confirmed cardiac wheeze. A good example is a patient that has Asthma and CHF presenting with wheezes. And it comes down to giving xopenex instead of albuterol because xopenex has less B1 effect with a good B2 effect.



Really...

First off if someone is suffering an asthma attack, while it is rather unpleasant for them, it isn't necessarily an immediately life threatening condition. Most patient's asthma won't progress, at least not that rapidly, to a state of respiratory failure. It isn't a condition we need to treat immediately unless the signs of respiratory failure are presenting. A full assessment should be done prior to any treatment.

Asthma is an inflammatory process with an increased mucus production actually making the bronchi "wetter" than dryer. Mucus is a combination of the secretion mucin, and water. Administering that beta agonist if anything causes the lungs to dry out more than remain moist. Especially if you administer atrovent.

Now, if you suspect someone of multiple pathologies or their history suggests it, it is even more reason to do a full assessment. Good lung sounds will tell you a lot about a patients condition and it couldn't be simpler to assess. Granted some patient's are difficult to auscultate more often than not its pretty easy if you keep the environmental noise to a minimum. Heart sounds could also be a good indicator of cardiac failure if you are competent enough to pick up a murmur that could suggest prolapse or regurgitation.

An ECG should always be performed prior to administering medication to a suspected CHF exacerbation. It may be an acute exacerbation of a chronic condition, it may be an acute episode of more substantial heart failure like an MI that can be detected via ECG.

If we decide the patient is suffering from CHF, NTG and CPAP are the current gold standard out of hospital. Anxiolytic if necessary to minimize the sympathetic response if your system permits it in some cases. Lasix is no longer considered a very viable treatment in acute exacerbation of CHF because the sympathetic response reduces renal blood flow making the effect of lasix very sparatic and often ineffective until the exacerbation is mostly resolved. It doesn't work to well if the kidneys are being disregarded. On top of that, CHF patients are often euvolemic or even hypovolemic. Rarely are they truly hypervolemic needing diuresis.

Quite often patients with COPD or asthma do have CHF and can very well be experiencing both problems but I would treat the CHF before I would treat the asthma every time. I would rather not make the heart work harder if it isn't completely necessary to proper care of the patient.




Firehazmedic said:


> Its just too easy to be wrong in this situation and it is much better to use xopenex as a diagnostic tool first to confirm suspicions.



It is wrong to administer unwarranted medications that have the potential to result in adverse reactions that the patient can't tolerate.


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## Sublime (Oct 15, 2012)

Firehazmedic said:


> Its just too easy to be wrong in this situation and it is much better to use xopenex as a diagnostic tool first to confirm suspicions.



I'm going to have to respectfully disagree. If your able to obtain a decent history and look for clues outside of just listening for wheezing I think you can make a pretty good clinical decision on whether or not to give nitro.

And I didn't know it was still the standard to give Lasix in CHF patients, especially pre-hospital. Most places I know have moved away from that and stick to ACE Inhibitors / Nitro / CPAP


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## MSDeltaFlt (Oct 15, 2012)

Firehazmedic said:


> Is there any agency out there that has a protocol for xopenex in place of albuterol for a suspected cardiac wheeze?


 
Absolutely not and I'll explain why.  Suspected "cardiac wheeze" is still Congestive Heart Failure with the operative word being *Failure*.  So why would you give a beta agonist (which stimulates the myocardium) to a heart that is already failing?

"Cardiac Wheeze" is not musical.  It's coarse; marked coarse to fine coarse, but still coarse.  That says fluid/edema: oxygen, nitrates (if VS/12-leads allow), and CPAP.  Auscultated bronchospasm is usually musical (not always I know), that in and of itself says "spasm" which screams "give bronchodilation".

Nebulized medications in the presence of fluid does precisely @#$% in achieving your patient care goals.


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## FLdoc2011 (Oct 15, 2012)

Sublime said:


> And I didn't know it was still the standard to give Lasix in CHF patients, especially pre-hospital. Most places I know have moved away from that and stick to ACE Inhibitors / Nitro / CPAP



Diuretics are still Grade 1B for acute decompensated heart failure from what I see and certainly still what our groups are doing.   

In regards to the original topic I agree,  a good history and exam should tell you which direction you're going to go with the patient.   Honestly, on the inpatient side we rarely use xopenex. I just don't think the evidence for it over albuterol is that good, and anecdotally I just don't see much difference clinically to justify using it much.   Exceptions may be if they had bad reaction to albuterol or they already took a dozen treatments at home before arriving and are now cruising along at 130 bpm or something.   Even in most cardiac pts (hx CHF, afib, etc...) I see albuterol tolerated well.


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## FLdoc2011 (Oct 15, 2012)

http://www.ncbi.nlm.nih.gov/pubmed/18572345

J Emerg Med. 2011 Feb;40(2):135-45. Epub 2008 Jun 24.

Should acute treatment with inhaled beta agonists be withheld from patients with dyspnea who may have heart failure?

Maak CA, Tabas JA, McClintock DE.
Source
Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA.


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## RocketMedic (Oct 15, 2012)

Firehazmedic said:


> Is there any agency out there that has a protocol for xopenex in place of albuterol for a suspected cardiac wheeze?



At EMSA, we can substitute prescribed xopenex for abuterol if the patient has a supply handy.


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## NomadicMedic (Oct 15, 2012)

Doesn't anyone else use end tidal caponography as a diagnostic tool? Asthma/COPD and CHF have very different looking wave forms.


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## RocketMedic (Oct 15, 2012)

n7lxi said:


> Doesn't anyone else use end tidal caponography as a diagnostic tool? Asthma/COPD and CHF have very different looking wave forms.



*Raises hand


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## MSDeltaFlt (Oct 15, 2012)

n7lxi said:


> Doesn't anyone else use end tidal caponography as a diagnostic tool? Asthma/COPD and CHF have very different looking wave forms.



I do.


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## DrankTheKoolaid (Oct 15, 2012)

Firehazmedic, go listen to EMcrit talk on SCAPE its like episode 1 or 2. It will make our answers make sense


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## Sublime (Oct 15, 2012)

FLdoc2011 said:


> Diuretics are still Grade 1B for acute decompensated heart failure from what I see and certainly still what our groups are doing.



Perhaps I worded it wrong. I know it is still the standard in many hospitals, but from what I understand physicians are slowly moving away from Lasix for emergent treatment of the unstable CHF patient. It certainly is in the pre-hospital side, I know we don't even carry Lasix anymore. We give Nitro / Captopril or Morphine / Enalaprilat along with CPAP. 

http://http://roguemedic.com/2012/06/chf-treatment-is-furosemide-on-the-way-out/

Also a direct quote from Dr. Scott Weingart of EMCRit when asked when to start diuresing SCAPE (Sympathetic Crashing Acute Pulmonary Edema) patients.



> When they are comfortable and the blood pressure is where you want, observe intravascular status. Then consider fixing it, usually the answer is they need fluid, not diuresis



EDIT: Here is a link to the podcast for the OP. http://emcrit.org/podcasts/scape/


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## AnthonyM83 (Oct 16, 2012)

Corky said:


> No as cardiac asthma is not an indication for a beta adrenergic that will potentially worsen the patients  condition by further increasing the work of the heart.



There's some strong statements on here about using albuterol on CHF patients. Yet, ER doctors routinely give it and are okay with giving providers giving it prehospital. 

Wasn't there a discussion about this awhile ago discussing benefits of opening up the airway that might be reactive to the lung fluid. The idea that it might not fix the cause, but help alleviate a symptom.

I'm not telling someone to do it one way or another, but consider that there ARE different acceptable ideas regarding this topic...


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## 325Medic (Oct 16, 2012)

n7lxi said:


> Doesn't anyone else use end tidal caponography as a diagnostic tool? Asthma/COPD and CHF have very different looking wave forms.



I do also.

325.


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## medicsb (Oct 18, 2012)

n7lxi said:


> Doesn't anyone else use end tidal caponography as a diagnostic tool? Asthma/COPD and CHF have very different looking wave forms.



I'd be careful referring to capnography as diagnostic.  I don't think there is any evidence to show it to be diagnostic.  I don't know of any numbers on the sensitivity and specificity or PPV and NPV of different waveforms in different conditions.  I'd wager that the waveform assoc'd with bronchoconstriction is specific but very non-sensitive.  Also if there is bronchiolar narrowing w/ cardiac wheeze (combination of edema and actual construction) and also with COPD, wouldn't the waveform potentially be similar?  Basically, do you have any evidence to back you claims?


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## NomadicMedic (Oct 18, 2012)

Well then let me recant my position a bit, in the interest of semantics. End-tidal waveform capnography may help differentiate between CHF and COPD. Waveforms between CHF and COPD are vastly different, even with slight bronchial constriction that may occur during CHF exacerbation. What you're looking for, is the expiratory plateau. CHF patients are not retaining CO2, however they may just have some bronchoconstriction which might give you a slight slur at the expiratory upstroke, but you see a relatively flat plateau.

Conversely, COPD patients are having difficulty in exhalation, and never can fully complete a true, CO2 rich exhale. That's why you won't see any of that flat plateau. 

And I'm on my phone at the moment so I can't get any databases, but a quick Google scholar look for peer-reviewed papers found this study that showed some significant differences in end-tidal CO2 capnometry, that is without waveform. The sample was small and they were not able associate anyone number with a predictor., however if they had had end tidal waveforms I'm sure it might've been a different story.

http://journal.publications.chestnet.org/article.aspx?articleid=1071323


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## NomadicMedic (Oct 18, 2012)

...And this this 2008 study that showed bronchodilator therapy in CHF patients resulted in the need for more aggressive treatments and the potential for less optimal outcomes?

http://www.medcontrol.com/omd_pub/bronchodilators.pdf

So, If you had the opportunity to use end tidal capnography to help guide your treatment, wouldn't that make more sense than blindly administering a beta agonist?


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## medicsb (Oct 18, 2012)

n7lxi said:


> Well then let me recant my position a bit, in the interest of semantics. End-tidal waveform capnography may help differentiate between CHF and COPD. Waveforms between CHF and COPD are vastly different, even with slight bronchial constriction that may occur during CHF exacerbation. What you're looking for, is the expiratory plateau. CHF patients are not retaining CO2, however they may just have some bronchoconstriction which might give you a slight slur at the expiratory upstroke, but you see a relatively flat plateau.
> 
> Conversely, COPD patients are having difficulty in exhalation, and never can fully complete a true, CO2 rich exhale. That's why you won't see any of that flat plateau.



I'm denying that expiratory obstruction can cause changes to the wave form, I just question how reliable the changes are (or their lack).  I used nasal EtCO2 frequently when I worked 911 - almost all respiratory patients, patients treated with opiates or benzos, some altered mental status, etc.  By and large, I noted some degree of "sloping" frequently in non asthma/COPD patients.  Unless the EtCO2 was particularly high or if the wave form was particularly slurred, I wouldn't hang my hat on it.  I personally find the greatest value of nasal EtCO2 to be for trending.  As far as I can tell, there is little information available on differentiating CHF from COPD with EtCO2, and most of what is out there seems to be anecdotal at best.  



> And I'm on my phone at the moment so I can't get any databases, but a quick Google scholar look for peer-reviewed papers found this study that showed some significant differences in end-tidal CO2 capnometry, that is without waveform. The sample was small and they were not able associate anyone number with a predictor., however if they had had end tidal waveforms I'm sure it might've been a different story.


 
In other words, the study yield no usable information.



n7lxi said:


> ...And this this 2008 study that showed bronchodilator therapy in CHF patients resulted in the need for more aggressive treatments and the potential for less optimal outcomes?



Yeah, I'm familiar with this study.  The study is interesting and makes a great case for the need for more research, but it does not show anything but correlation.  We do NOT know if bronchodilators made anyone worse; it is very well possible that their use indicates a sicker patient (just like that morphine and NSTEMI study from years back).  



> So, If you had the opportunity to use end tidal capnography to help guide your treatment, wouldn't that make more sense than blindly administering a beta agonist?



It would be another piece of information to be considered, for sure.  I don't think anyone has advocated blindly giving bronchodilators to CHF patients, though.


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## 18G (Oct 18, 2012)

medicsb said:


> I'd be careful referring to capnography as diagnostic.  I don't think there is any evidence to show it to be diagnostic.  I don't know of any numbers on the sensitivity and specificity or PPV and NPV of different waveforms in different conditions.  I'd wager that the waveform assoc'd with bronchoconstriction is specific but very non-sensitive.  Also if there is bronchiolar narrowing w/ cardiac wheeze (combination of edema and actual construction) and also with COPD, wouldn't the waveform potentially be similar?  Basically, do you have any evidence to back you claims?



I had a status asthmaticus patient a few days ago I transferred IFT. Pt. was intubated and on the vent. Initial EtCO2 was around 80mmHg with near absent lung sounds. The EtCO2 wave form was normal and not the characteristic "shark fin". So this is a good example of not hanging your hat on the capnography waveform. 

I gave my patient a Duoneb followed by continuous albuterol treatments over the 45min transport. EtCO2 came down to 59mmHg.


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## NomadicMedic (Oct 19, 2012)

You would expect to not see a shark fin on a vented pt with a high level of PEEP, right? (I'm not a vent whiz, just trying to think this through...)

Prior to the vent, I'd guess that bagging the patient still showed a sharkfin... With it only disappearing as the PEEP was increased.


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## Handsome Robb (Oct 19, 2012)

So my question is why even use capnography then for anything other than confirming ETT placement if you aren't going to use the information it gives you along with a good assessment to guide your treatment?


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## KellyBracket (Oct 19, 2012)

FLdoc2011 said:


> http://www.ncbi.nlm.nih.gov/pubmed/18572345
> 
> J Emerg Med. 2011 Feb;40(2):135-45. Epub 2008 Jun 24.



Thanks for the reference! Don't know how I missed it, but the result fits with how most of us practice.

This subject is fascinating, and comes up frequently on this forum. Back in the spring people were weighing in in the thread " *Administration of bronchodilators for pulmonary edema*?" It was a "spirited" discussion, and it got me thinking, and reading.

I put together a small review of the topic, to be used for an EMS talk in the future:  *"All that wheezes" - CHF and albuterol*. My summary:

Medics are able to diagnose CHF with pretty good accuracy, and capnograhy _may_ be a helpful adjunct for them.
CHF frequently presents with wheezing, especially in older patients.
The dangers of giving beta-blockers are controversial, and was mentioned earlier, may just be a marker of the sick patient.


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## NomadicMedic (Oct 19, 2012)

18G said:


> I had a status asthmaticus patient a few days ago I transferred IFT. Pt. was intubated and on the vent. Initial EtCO2 was around 80mmHg with near absent lung sounds. The EtCO2 wave form was normal and not the characteristic "shark fin". So this is a good example of not hanging your hat on the capnography waveform.
> 
> I gave my patient a Duoneb followed by continuous albuterol treatments over the 45min transport. EtCO2 came down to 59mmHg.



But following my other comment about the shark fin not showing up with a high-level of peep for patient on  a vent… Your patient also had a history of asthma, correct? This was also an IFT, not an original presentation. Would you expect to see a shark fin presentation on end title capnography with the original status asthmaticus patient? 

If this were a 911 call, would you, not knowing the patient's current situation, administer bronchodilators simply because the patient has a history of asthma?

Of course you would. It's only prudent.

But if this same patient presented with a flat topped capnography waveform, had no history of asthma or COPD but did have a history of CHF and expiratory wheezes ... would you still go down the bronchodilator route?

I understand your reasoning of "not hanging your hat on a waveform", but common sense and past medical history will give you a pretty good idea as to what road you're going down. I think capnography is useful when I'm trying to weigh the differential between CHF and COPD when the patient has a history of both. I may be going out on a limb, but I feel a CO2 retainer who may, or may not, present with a shark fin waveform, it's going to be a COPD/reactive airway disease patient vs CHF. I'll be sure to examine all the other clinical findings… But capnography is a great tool to help guide me down the road of treatment.


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## KellyBracket (Oct 22, 2012)

KellyBracket said:


> I put together a small review of the topic, to be used for an EMS talk in the future:  *"All that wheezes" - CHF and albuterol*. My summary:
> ...



Somehow I didn't properly link the review.
*"All that wheezes" - CHF and albuterol*


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## NYMedic828 (Oct 22, 2012)

KellyBracket said:


> Since most paramedics are 1) intelligent, 2) clever,  and 3) convinced they are more clever than the other medic they're arguing with



:rofl::rofl::rofl:


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