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



## Jay506 (May 15, 2015)

This is one of those things that I like to hear from active medics about.  It's probably simple but it's something that confuses me.  When do YOU give a breathing treatment and why do you or don't you give albuterol and atrovent or just albuterol?


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## Accelerator (May 15, 2015)

I like to look at the capnography before I give a duoneb treatment. Especially if the patient already is tachycardic. Sometimes that's not always an option. Always listen to breathe sounds. Any sort of wheezing and it's probably a good bet to give a duoneb. Our protocol also recommends it for pneumonia. 

I always give both drugs together. If they need one they'll probably need the other.


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## Akulahawk (May 16, 2015)

I do an assessment before starting a breathing treatment on someone. That assessment can happen very rapidly and I always listen to the lungs. Wheezing is one thing, but I get more worried about diminished breath sounds in the setting of much SOB and increased work of breathing. Most of the time I'll call for a DuoNeb for the same reason as above... if they need one, they'll probably need the other and it's a combo that works pretty well most of the time. 

Something to remember is that when you have a patient that's so diminished that they're not wheezing at all and they start wheezing during or just after a breathing treatment, it's probably because their lungs are starting to open up enough to allow the wheezing to occur. They sound worse, but it's actually an improvement.


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## Jay506 (May 16, 2015)

Great info, thanks!


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## NomadicMedic (May 16, 2015)

I've only seen a couple of studies that have been conducted to establish efficacy of albuterol alone versus albuterol with ipratroprium. Most of them were old, from the 90s.

It seemed as though there was no statistical difference in outcome of the majority of asthma patients that received just albuterol versus the Combivent. There was a group of elderly COPD patients that DID have improved outcome with the addition of ipratroprium.

Just like much of the medicine we practice, ipratroprium falls into the "probably won't hurt, and might help" camp. I asked the doc at the ED about it this morning, and that was his quick answer.



Here's a couple of links:

http://informahealthcare.com/doi/abs/10.1080/10903120500255404


http://www.ncbi.nlm.nih.gov/m/pubmed/8797400/


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## 04_edge (May 16, 2015)

We only carry Albuterol at my service, and really patient presentation dictates how early or late i give it.  If they are working pretty hard to breath, generally we get them to the truck, throw the pulse ox on real quick, listen to breath sounds, and while I'm doing that my partner is getting the neb ready. I like to get them on ETCo2 as quickly as possible as well, seeing their I:E normalize is a pretty good early indicator of how well treatment is working and if they are going to require further intervention.  On a side note, we carry brethine, and if there is any decrease in lung sounds on initial auscultation i usually give that along with the first neb and have had great results with it.


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## Gurby (May 16, 2015)

I was just reading about ipratropium on wikipedia last night!  Pretty interesting drug.  It's actually a derivative of atropine, but does not diffuse into the blood - thus, it shouldn't really complicate things cardiac-wise (which is kind of the only concern with giving albuterol).  It has a different mechanism from albuterol (it blocks acetylcholine receptors as opposed to albuterol which is a beta agonist) which is nice - if the patient is calling you for an asthma exacerbation they've probably already taken their inhaler a bunch and it hasn't helped, so going down a different path (in addition to higher dose of albuterol) could help.

I've seen ED docs order plain albuterol before, but I think the only situation where I'd do that in the field is if patient has an allergy to ipratropium (or atropine), or something like that.


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## TheLocalMedic (May 18, 2015)

@Gurby The reason you don't see Atrovent being ordered with albuterol in the hospital setting is because albuterol can pretty much be continuously given while atrovent needs only to be given at intervals, and too much can be harmful.  If EMS brings in a patient that has already gotten a dose of atrovent, then there is no reason for the ED to give even more.  

Most people with asthma, pneumonia or COPD exacerbation will get both albuterol and atrovent in the first neb treatment I give, but I tend to limit that to only albuterol in pediatric patients unless they're more severely dyspneic.


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## RocketMedic (May 18, 2015)

To expand on that,  there's not a lot of benefit to continuous atrovent treatments. Initial duoneb, additional albuterol-only


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## Handsome Robb (May 18, 2015)

We give up to 5mg of atrovent before we go albuterol only. 

At that point if it's not helping it won't do any good giving more as others have said.


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## wanderingmedic (May 18, 2015)

To add another option to the discussion, I really like Xopenex. I have found it doesn't seem to induce tachycardia like albuterol does, and is just as effective for opening diff. breathers up. I really like it as an option when patients are not responding well to albuterol, or have been repetitively using an albuterol inhaler prior to our arrival. Unfortunately, my current service does not carry it, and it does not seem like many services have it on their trucks.


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## chaz90 (May 18, 2015)

Handsome Robb said:


> We give up to 5mg of atrovent before we go albuterol only.
> 
> At that point if it's not helping it won't do any good giving more as others have said.


5 mg or 0.5 mg? I've always seen Atrovent dosed at 0.5 mg, so it would blow my mind if someone were giving 10x that dose.


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## Handsome Robb (May 18, 2015)

chaz90 said:


> 5 mg or 0.5 mg? I've always seen Atrovent dosed at 0.5 mg, so it would blow my mind if someone were giving 10x that dose.



You're right. And we can give up to 1.0 mg.

Whoops haha. Not sure how I ended up at that number.


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## polisciaggie (May 18, 2015)

azemtb255 said:


> To add another option to the discussion, I really like Xopenex. I have found it doesn't seem to induce tachycardia like albuterol does, and is just as effective for opening diff. breathers up. I really like it as an option when patients are not responding well to albuterol, or have been repetitively using an albuterol inhaler prior to our arrival. Unfortunately, my current service does not carry it, and it does not seem like many services have it on their trucks.



I too prefer Xopenex, unless the patient is allergic to it I pretty much always use that instead of Albuterol. There is one patient in my service area that is highly allergic to Xopenex, had to be tubed twice because of it but responds to Albuterol great.


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## wanderingmedic (May 18, 2015)

polisciaggie said:


> I too prefer Xopenex, unless the patient is allergic to it I pretty much always use that instead of Albuterol. There is one patient in my service area that is highly allergic to Xopenex, had to be tubed twice because of it but responds to Albuterol great.



For whatever reason, it seems like Xopenex is much more popular in Texas and the south than other states.


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## Tigger (May 19, 2015)

We are capped at .5mg of atrovent. Our medical director prefers that the first treatment be albuterol only. If you think the patient could benefit from an an additional neb, that's when atrovent is considered.


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## Carlos Danger (May 19, 2015)

polisciaggie said:


> I too prefer Xopenex, unless the patient is allergic to it I pretty much always use that instead of Albuterol.



Levalbuterol (xopenex) and albuterol are essentially the same drug. Just different isomers of the same chemical. Equal in efficacy.


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## Rialaigh (May 19, 2015)

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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## NomadicMedic (May 19, 2015)

Rialaigh said:


> 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.



...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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## Clare (May 20, 2015)

For mild asthma or COPD use the pts own MDI/spacer if they have it available. 

If their asthma or COPD is moderate or severe give nebulised salbutamol (continuously if severe) and one dose of 0.5 mg of ipratropium.

For a pt with severe asthma/COPD the rationale for continuous nebulised salbutamol is that it maximises the amount available even if their tidal volume is poor.  Obviously if you need to hand ventilate them then stop giving it! 

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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## Rialaigh (May 20, 2015)

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.



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.



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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## Ewok Jerky (May 20, 2015)

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...


Pretty sure she is not in the US (NZ maybe?) so that's your answer right there.


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## YoungMedic (May 20, 2015)

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.


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## DrParasite (May 24, 2015)

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.


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 (Jun 1, 2015)

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.
> 
> ...



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


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## Medic Tim (Jun 1, 2015)

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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## polisciaggie (Jun 5, 2015)

Remi said:


> Levalbuterol (xopenex) and albuterol are essentially the same drug. Just different isomers of the same chemical. Equal in efficacy.



I know, was just saying I prefer using it.


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## Louis Sabat (Jun 10, 2015)

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


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## FltMedicRob (Jun 15, 2015)

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 (Jun 15, 2015)

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.
> 
> ...



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.


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## NomadicMedic (Jun 15, 2015)

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.


 This is usually my plan of action. Fix what you can fix and repeat your assessment to determine which pathway to continue down.


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## Uclabruin103 (Jun 17, 2015)

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



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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