# HHN vs MDI



## bstone (Apr 7, 2009)

New Hampshire just updated the Intermediate protocols and we all have to take yet another transition course. The new course calls for "Albuterol HHN". I tried googling it but I cannot find that HHN means. I think it means via nebulizer as opposed to Metered Dose Inhaler (MDI). 

If I am correct then I wonder why they want us to learn this as it was part of the initial training. I wonder what changed. I guess I will find out soon.

So, am I right about HHN? Vent? Rid?


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## AJ Hidell (Apr 7, 2009)

HHN = Hand Held Nebuliser







What you need to learn about it is a lot more than simply how to work it (which few EMT or medic schools teach well).  There is a lot of pharmacology involved in the intelligent and competent administration of sypathomimetics.  Whatever they give you, it won't be enough.


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## MSDeltaFlt (Apr 7, 2009)

For the truely dyspneic pt due to bronchospasm, proper administration of MDI will be problematic at best.  Dang near impossible.  In these cases you'll be able get to more medication to the distal bronchioles with a neb.


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## VentMedic (Apr 7, 2009)

MSDeltaFlt said:


> For the truely dyspneic pt due to bronchospasm, proper administration of MDI will be problematic at best. Dang near impossible. In these cases you'll be able get to more medication to the distal bronchioles with a neb.


 
Not always true. We have liberal tritrate for response protocols in our ED which makes the MDI a quick delivery of a higher dose. 

Unless you have a breath activated nebulizer, delivery for HHN is about 20% at best. We will also use a higher dose over a shorter period of time with a BAN. But, MDI is still my preferred short term rescue for many patients. The new HFA MDIs have been slightly more challenging to adapt inline with BVMs and ventilators. Also, if you do not have an aerochamber, the delivery will not be as good. Open mouth technique is no longer advised with the HFA MDIs. 

Providers should also become familiar with the new inhalers and meds that are available. We recently had an EMS crew encouraging the patient to take what they thought was a rescue inhaler between nebs. This was even with the patient telling them it wasn't but they kept assuring the patient they were monitoring and it was okay because they said so. The med was Symbicort. The patient ended up on a tele floor for cardiac observation as well as his breathing problems.


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## bstone (Apr 7, 2009)

Ok, so HHN is a "regular" nebulizer. I wonder why they want us to be trained on it as we already were in Intermediate school. We had a full exam on the pharmacology and mechanism of action of albuterol, indications, etc 

Odd.

But thank you for defining HHN!


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## VentMedic (Apr 7, 2009)

bstone said:


> Ok, so HHN is a "regular" nebulizer. I wonder why they want us to be trained on it as we already were in Intermediate school. We had a full exam on the pharmacology and mechanism of action of albuterol, indications, etc
> 
> Odd.
> 
> But thank you for defining HHN!


 


What's wrong with another training class? RRTs have to review even the simplest of RT equipment including the HHN and meds year for competency requirements and each time a new piece of equipment or brand is introduced. HHNs come in many different shapes and particle size capabilities as well different types for different meds. 

Learning shouldn't be a one time deal. The way you learned something as an EMT B or I may be very different than the expectations for learning as  a Paramedic. The Paramedic should have a more thorough understanding of the uses for the respiratory meds from an advanced level. Another example of this would be the difference of how BP is seen through the education of an EMT and the Paramedic. Even though "BP" is taught at both levels, one would hope the Paramedic can get a little more from its application. I'm pretty sure that even at the Paramedic level you will not understand or get the same education for the HHN and Albuterol as an RRT or RN.


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## bstone (Apr 7, 2009)

Oh there is absolutely nothing wrong with more classes. I am highly in favor of it as part of a regular refresher. I just did a refresher which covered this and many of the other basics.

What I am confused about if they are advertising HHN Albuterol as _new_ for Intermediates. That's just not true. We were trained on it and it's part of our protocols for years. It's never been taken out of the protocols, either. 

Oh well. Now I just wait until the class is held. Thanks for the info!


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## AJ Hidell (Apr 7, 2009)

Not all EMT schools are worth a darn.  I am sure that you have graduates from multiple schools in your organization.  You probably also have EMTs who have never done an HHN since they graduated and started looking for a job two years ago.  Not to mention the very low retention rate of EMT-B information.  Any employer would be negligent to just assume that any EMT-B they employ is competent with no documentation.  Every hospital I have ever worked for required new nurses to be oriented and checked off on skills in-house, regardless of license or experience.  This pervasive attitude that anyone with an EMT patch is competent, and doesn't need any more education, is one of the biggest factors holding EMS in the 1970s.


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## bstone (Apr 7, 2009)

AJ Hidell said:


> Not all EMT schools are worth a darn.  I am sure that you have graduates from multiple schools in your organization.  You probably also have EMTs who have never done an HHN since they graduated and started looking for a job two years ago.  Not to mention the very low retention rate of EMT-B information.  Any employer would be negligent to just assume that any EMT-B they employ is competent with no documentation.  Every hospital I have ever worked for required new nurses to be oriented and checked off on skills in-house, regardless of license or experience.  This pervasive attitude that anyone with an EMT patch is competent, and doesn't need any more education, is one of the biggest factors holding EMS in the 1970s.



We're not EMT-Bs. We're EMT-Is. It was an additional semester, 210 hours in addition to the 140 Basic.

But I think that being checked off is a fine idea. More ConEd is never a problem. I don't mind being retrained and reeducated.


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## MSDeltaFlt (Apr 9, 2009)

VentMedic said:


> *Not always true*. We have liberal tritrate for response protocols in our ED which makes the MDI a quick delivery of a higher dose.
> 
> *Unless you have a breath activated nebulizer, delivery for HHN is about 20% at best*. We will also use a higher dose over a shorter period of time with a BAN. But, MDI is still my preferred short term rescue for many patients. The new HFA MDIs have been slightly more challenging to adapt inline with BVMs and ventilators. *Also, if you do not have an aerochamber, the delivery will not be as good. Open mouth technique is no longer advised with the HFA MDIs*.
> 
> Providers should also become familiar with the new inhalers and meds that are available. We recently had an EMS crew encouraging the patient to take what they thought was a rescue inhaler between nebs. This was even with the patient telling them it wasn't but they kept assuring the patient they were monitoring and it was okay because they said so. The med was Symbicort. The patient ended up on a tele floor for cardiac observation as well as his breathing problems.


 
You are correct as always, Vent.  I was speaking only from the point of view of level of health care in my area which is reminiscent of the Dark Ages.


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## VentMedic (Apr 9, 2009)

MSDeltaFlt said:


> You are correct as always, Vent. I was speaking only from the point of view of level of health care in my area which is reminiscent of the Dark Ages.


 
The Asthma Educators conference will be in New Orleans this year if you are interested in some CEUs for your RT license. It is definitely a good conference. 

http://www.asthmaeducators.org/Conference/index.htm

Association of Asthma Educators
http://asthmaeducators.org/

The EPR-3 guidelines for asthma are now in use.

It is amazing at how many changes happen almost yearly in the cardiopulmonary areas of medicine. Those that believe they learn it all in one class and that is all there is are fooling themselves. Medicine keeps evolving even if some in EMS don't.


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## Melbourne MICA (Apr 12, 2009)

*self administering*

We use a "t" piece attachment as an alternative to a neb mask for pt's who won't tolerate a mask. Bronchodilator meds are then self administered. The t piece is very similar in appearance to the HHN just lacking the extension tube.

But aren' all these neb devices ventilation dependent and thus directly proportional in delivery and symptom relief effectiveness? Once any pt with small airways obstruction cannot produce decent inhaltion volumes then IV therapy is indicated and more effective. Nicht wah?

MM

PS Agree with Venty about further training provided the training is also contemporary and an expansion of existing education. We don't need more technicians we need educated professionals as a general principle I would have thought.


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## VentMedic (Apr 12, 2009)

Melbourne MICA said:


> We use a "t" piece attachment as an alternative to a neb mask for pt's who won't tolerate a mask. Bronchodilator meds are then self administered. The t piece is very similar in appearance to the HHN just lacking the extension tube..


 
I try to not use a mask with adults if at all possible and will try to get kids starting at the age of at least 4 y/o to go with a mouth piece. The mask does not encourage much of an inspiratory effort. As well, none of the respiratory meds or whatever the patient coughs out belongs in the eyes. I do prefer to leave the flex extension tubing on to keep the meds away from the face and to allow for a little extra O2 concentration. Years ago and even now, we will do a nose clip with respiratory treatments. 

From the respiratory effort made from the use of a neb and mouthpiece, one can get a good idea about the maitenance and rescue meds the patient may be able to use. Each MDI actually has different inspiratory force requirements to activate and their own learning curve for use. Apply that to what the insurance or assistance clinics will pay for, choosing the right MDI for the long haul can get challenging. 



Melbourne MICA said:


> But aren' all these neb devices ventilation dependent and thus directly proportional in delivery and symptom relief effectiveness? Once any pt with small airways obstruction cannot produce decent inhaltion volumes then IV therapy is indicated and more effective. Nicht wah?


 
No, most nebulizers could care less if you are breathing or not which is why we prefer the breath activated nebs. IV therapy for inflammation, infection and hydration is still indicated in many situations with the nebulized bronchidilators and/or corticosteroids being relief and supplemental/adjunct therapies. 

There are many different types of nebulizers/devices on the market that are better for different purposes and/or medications. Just for nebulizers, some do not understand the fill limitations or baffling principles and will over fill the small acorn neb in an attempt to simulate a "continuous" neb. They essentially have made any particle delivered by that neb useless due to the reduced effectiveness of the baffle by the volume. 




Melbourne MICA said:


> PS Agree with Venty about further training provided the training is also contemporary and an expansion of existing education. We don't need more technicians we need educated professionals as a general principle I would have thought.


 
In the past we had staffed the ED with RTs who were adrenaline junkies that preferred "skills" like intubation, IVs,ABGs and a "good code" to the brain work and teaching chores in the ICUs and on the med-surg floors. Now, we want all RRTs to be Asthma and COPD educators especially if they work in the ED. Often the patient will bring in 10 -15 different MDIs, all samples from their PCP, and will know little to nothing about how, when and why. They just know they still can not breathe. 

So, with the many different meds, types of inhalation devices, inconsistent knowledge of the PCPs, mixed messages at the clinics or EDs and the insurance companies, is there little wonder as to why patients get confused and sometimes just give up to become noncompliant?


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## el Murpharino (Apr 12, 2009)

Vent, what have you found in your experience with nebs given via BVM?  I've always held the belief that if you need to give a neb via BVM, you may want to be thinking intubation.


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## Melbourne MICA (Apr 12, 2009)

VentMedic said:


> No, most nebulizers could care less if you are breathing or not which is why we prefer the breath activated nebs. IV therapy for inflammation, infection and hydration is still indicated in many situations with the nebulized bronchidilators and/or corticosteroids being relief and supplemental/adjunct therapies.



Sorry Venty - I didn't explain my comment very well. 

Resolution of bronchospasm via any kind of inhaled therapy is dependent on them being able to inhale sufficient quantities for a therapeutic effect. So once the acute asthmatic becomes profoundly fatigued for example with very low inspiratory volumes ie very "tight" then neb therapy will be largely ineffective hence my comment to move to IV bronchodilator therapy as well corticosteroids etc.

Also there is the problem of self administration. With hypercapnoea/emerging hypoxia and acute anxiety the acute asthmatic for example will be battling with every breath and in my experience spending more time in dependent posturing efforts than wanting to hold something to their mouth. Our guidelines emphasize an open mouth breathing approach with neb mask and the switch to +/- IV therapy once the situation gets out of hand - ie clinically insp + exp bronchoconstriction or profound fatigue/poor RSA numbers.

I guess in a compliant pt managing self admin the best dose delivery method is what works - as you say lots to choose from.

As an aside Neb Adrenaline has been used in some ED's here to attack the severe asthmatic episode in particular at its core - ie the inflammation.

"Our Ambulance Docs (who include outside resp specialists) have debated this approach for many years but still fall back to bronchodilator therapy + steroids. Also we haven't changed from Neb mask or T piece delivery then IV therapy for years.

As I understand it even with complete relief of bronchospasm irrespective of how this is achieved, ie no wheezes whatsoever, a Pt's small airways can still be up to 50% obstructed. 

Another interesting area of resp medicine suffice it to say
Cheers

MM


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## VentMedic (Apr 13, 2009)

Melbourne MICA said:


> Sorry Venty - I didn't explain my comment very well.
> 
> Resolution of bronchospasm via any kind of inhaled therapy is dependent on them being able to inhale sufficient quantities for a therapeutic effect. So once the acute asthmatic becomes profoundly fatigued for example with very low inspiratory volumes ie very "tight" then neb therapy will be largely ineffective hence my comment to move to IV bronchodilator therapy as well corticosteroids etc.
> 
> ...


 
Too fatiqued? These patients you do not wait and see what the neb will do. You get your line in and be read to go with addtional fluids and/or meds. As well, you may consider supporting ventilation if you have that capability. CPAP does not always work on asthmatics and can even be dangerous for some. BiPAP(Respironics trade name) can help a little better but again needs to approached with caution for more air trapping and decreased hemodynamics.

Due to inflammation and thick secretions, you may not get clear breath sounds after an Albuterol treatment. The patient may still have wheezes several days later after antibiotics, steroids and continuous nebulizer treatments but has a greatly increased Peak Expiratory Flow Rate. 

The mask, even with open mouth, does not always encourage adequate breaths. It rather encourages a passive attitiude of "I've given the med". If you only have one patient YOU can assist holding the nebulizer in place and making it an active therapy session. I do this even while starting an IV with a little creative positioning. However, some patients may become mouth breathers when nearing failure and the mask may work okay. Of course, it will still vary with the type of nebulizer and particle size or efficiency of its delivery.

The mouth piece also allows me in the hospital to attach adjunct devices such as PEP or Flutter to assist in airway opening or mucus clearing. We also don't like to encourage open mouth technique as we are now in the process of retraining patients to NOT do this method when they take their MDIs since the HFA propellant is lighter and may not make it to the airways if too far. Of course, a spacer or holding chamber is the preferred method.

If the patient is already on the steps of respiratory failure, mask or mouth piece may not work.

The person can make every attempt to breathe deeply with open mouth or mouth piece but the narrowing will still prevent airflow or particle distribution. That is when we bring in the heliox for ventilation assist and particle delivery with or without a ventilator. I've had asthma patients on heliox by ventilator for over a week to support ventilator and medicine delivery while whatever infection and inflammation was causing the narrowing of the airways.

Neb Adrenaline does not attack the inflammation. We have used that on and off for years until other bronchodilators came about. Nebulized corticosteroids can help with the process and are used earlier for the inflammation of the asthma and inflamed throats from repeated or bad intubation attempts. IV steroids are also started. For some asthmatics, antibiotics will be necessary to treatment more than just an inflammation. PNA makes for a bad time for any asthmatic.

Unfortunately many ED physicians (and PCPs) do not stay current with the latest asthma or COPD treatments. That is why we now have people who are asthma educators around to assist. If the educator is an RRT, RNs are still the larger number of educators, they have a direct link to a Pulmonologist as an additional consult. 

Here are the EPR-3 guidelines. I believe they are similar to the Australian/NZ, European and Canadian guidelines since these are formed with international sharing of information. The U.S., of course, is often at a disadvantage when it comes to the newer meds or delivery methods that are already available in other countries. Also, keep in mind this is for asthma. When there are other disease processes such as other forms of COPD, the guidelines change which is why they are guidelines and not just recipes or protocols. We make our protocols from these guidelines for some initial treatment but then may choose other pathways as further assessment is done.

U.S. EPR-3
http://www.nhlbi.nih.gov/guidelines/asthma/index.htm

Australia/NZ
http://www.thoracic.org.au/glasthma.html

Canada
http://www.lung.ca/cts-sct/guidelines-lignes_e.php

*For those who believe they know everything there is to know about "a nebulizer":*

European article about nebulizers: 

http://www.erj.ersjournals.com/cgi/reprint/18/1/228.pdf

Performance Comparison of Nebulizer Designs:
Constant-Output, Breath-Enhanced, and Dosimetric​http://www.rcjournal.com/contents/02.04/02.04.0174.pdf

*Good overview:*
Comparing Clinical Features of the Nebulizer,
Metered-Dose Inhaler, and Dry Powder Inhaler​http://www.rcjournal.com/contents/10.05/10.05.1313.pdf


Heliox nebulizer (relatively new)
http://www.rcjournal.com/abstracts/2007/?id=aarc07_60

Heliox and albuterol
http://www.rcjournal.com/abstracts/2003/?id=OF-03-262

Heliox and ventilators
http://www.rcjournal.com/contents/06.06/06.06.0632.pdf

An interesting case study (just to show off an every changing field of specialty medicine):

HELIOX ADMINISTRATION DURING HIGH-FREQUENCY JET VENTILATION
http://www.rcjournal.com/contents/09.04/09.04.1038.pdf​


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## VentMedic (Apr 13, 2009)

el Murpharino said:


> Vent, what have you found in your experience with nebs given via BVM? I've always held the belief that if you need to give a neb via BVM, you may want to be thinking intubation.


 

If I have to bag a patient, I will be considering the next step for airway management. Fortunately, even on transport, I can do NIV with the LTV 1200 ventilator if I believe I can manage their airway well enough. If I am doing most of the assisting or initiation of each breath with the BVM, the patient gets a tube. If there are other systems and disease processes that will require intensive treatment, ETI may be preferred. You may also need to free up your hands to initiate other therapy such as an IV and fluids/meds. It is easier to do that with an ETT. Also, if the patient air-traps or other systems are affected by disease processes such as in infection/sepsis to a point where they become hemodynamically unstable, you are ready. 

Occasionally in the ED, we use a flow dependent BVM like a Jackson Reese setup to do CPAP and med delivery. The med delivery by that method is controversial due to the speed of gas flow but it can be adjusted with an inline nebulizer. 

I have used the bag to tube method with an inline nebulizer many times until an appropriate ventilator and/or gas is connected. Transport ventilators are not always designed to handle difficult respiratory patients and I prefer a ventilator with a waveform monitor when delivering mechanical breaths. Bagging may not always be that efficient for stabilizing gas exchanging but I can still feel the compliance and with a few years of practice, your timing can be as good as a sophisticated ventilator...sometimes.


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## MSDeltaFlt (Apr 13, 2009)

VentMedic said:


> If I have to bag a patient, I will be considering the next step for airway management. Fortunately, even on transport, I can do NIV with the LTV 1200 ventilator if I believe I can manage their airway well enough. If I am doing most of the assisting or initiation of each breath with the BVM, the patient gets a tube. If there are other systems and disease processes that will require intensive treatment, ETI may be preferred. You may also need to free up your hands to initiate other therapy such as an IV and fluids/meds. It is easier to do that with an ETT. Also, if the patient air-traps or other systems are affected by disease processes such as in infection/sepsis to a point where they become hemodynamically unstable, you are ready.
> 
> Occasionally in the ED, we use a flow dependent BVM like a Jackson Reese setup to do CPAP and med delivery. The med delivery by that method is controversial due to the speed of gas flow but it can be adjusted with an inline nebulizer.
> 
> I* have used the bag to tube method with an inline nebulizer many times until an appropriate ventilator and/or gas is connected*. Transport ventilators are not always designed to handle difficult respiratory patients and I prefer a ventilator with a waveform monitor when delivering mechanical breaths. *Bagging may not always be that efficient for stabilizing gas exchanging but I can still feel the compliance and with a few years of practice, your timing can be as good as a sophisticated ventilator...sometimes*.


 
On my part time ground service (which does not have RSI), I've used inline nebs with BVM and also BVD/ETT depending on my pt's status and/or how close I am to the ED.  Also, depending on how much autoPEEP they have from bronchospasm, I might, I repeat *might*, add a PEEP valve to the end of the BVM/BVD.  Usually the pt's condition won't let me.


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