# o2 flowrate for Albuterol



## goidf

Albuterol is supposed to be administered so that the treatment lasts 5-15 minutes. What exactly is the o2 flow rate that will fit that criteria, and does that rate change when you add an ipratropium? (doubling the amount of fluid in the treatment)


----------



## Shishkabob

4-8lpm, with caution to the specific device you're using as some nebulizers simply will not stay connected at anything over 8lpm.


----------



## Smash

Who cares how long it takes?

Use the flow rate for the device that optimises the production of particles of 5micrometer size.  Low flow rates will produce droplets that are larger and they will be deposited in the upper airways.  High flow rates will produce smaller particles that will be exhaled or hang around in the conducting airways without being deposited.  Most commercial nebulisers that I am aware of are designed to work optimally with flow rates between 6-8l/m.

Better yet, unless there is a reason not to, use a metered dose inhaler.

Maybe one of the RTs on the board could explain it better or further.


----------



## mycrofft

Linuss said:


> 4-8lpm, with caution to the specific device you're using as some nebulizers simply will not stay connected at anything over 8lpm.



True that,


----------



## mycrofft

Smash said:


> Who cares how long it takes?
> 
> Use the flow rate for the device that optimises the production of particles of 5micrometer size.  Low flow rates will produce droplets that are larger and they will be deposited in the upper airways.  High flow rates will produce smaller particles that will be exhaled or hang around in the conducting airways without being deposited.  Most commercial nebulisers that I am aware of are designed to work optimally with flow rates between 6-8l/m.
> 
> Better yet, unless there is a reason not to, use a metered dose inhaler.
> 
> Maybe one of the RTs on the board could explain it better or further.



Sometimes the MD has a written order of duration and dose. Sometimes it will even work with the devices at hand.


----------



## ThadeusJ

I'm an RT...the flow rate depends on the delivery device and most of the nebulizers suggest 6-8 Lpm.  Note that there is a general limit to the volume to be administered as well.  I have seen (far too many times) people giving a premixed vial of medication (i.e. saline is already in there), adding a second premixed medication with its saline and then adding yet more saline to create one whopping dose that will not only last forever but spill all over the place.  As mentioned above, the key is to 
generate the right particle size.  If you overload the nebulizer, cranking it up isn't going to help the patient any.

My suggestion is to review the medication(s) you are giving (dose and packaging), read the P&P to make sure it doesn't conflict by suggesting that you add additional saline (written from the days of yore when you had multi-use bottles) and then see how it matches up with the equipment you are given to administer it/them.  Then go with a MDI method...


----------



## medicdan

Arent MDIs generally used incorrectly and ineffecient at medication delivery? Does a demand inhalator exist for a neb?


----------



## Handsome Robb

Our nebulizers are designed to run at 6 lpm with no more than 3.5cc of fluid in them. 

6-8 LPM is what I've always been told, depending on the manufacturer's reccomendation for that specific device, like others have already said. If you're dead set on further increasing the FiO2 beyond what's being provided by the nebulizer you can always place a nasal cannula as well. 

Always makes me giggle when we walk in and the FD has a neb setup and is flowing 15 LPM through it.


----------



## Handsome Robb

emt.dan said:


> Arent MDIs generally used incorrectly and ineffecient at medication delivery? Does a demand inhalator exist for a neb?



I'm not sure they'd continually be prescribed if they were inefficient at medication delivery. 

I agree though about how they're used incorrectly the majority of the time. Often by patients who've been using them for years!


----------



## Medic Tim

I much prefer an mdi over nebs. With a chamber they are very effective. Most pts i have seen prefer them as they only have to take a few deep breaths and hold it ,vs having a neb on for a while that may not  be effective if they are breathing shallow or sob.


----------



## Handsome Robb

Anyone have a preference on hand held nebs vs nebs on a mask? 

I tend to try and push my patients to let me put it on a mask for them since the majority of the time all they do is hold the neb and wave it around, spilling all the medication out of it, rather than breathing through it. 

Obviously don't force them but unless they directly ask for the handheld nebulizer I just set it up on a mask and don't give them the option.


----------



## Christopher

Medic Tim said:


> I much prefer an mdi over nebs. With a chamber they are very effective. Most pts i have seen prefer them as they only have to take a few deep breaths and hold it ,vs having a neb on for a while that may not  be effective if they are breathing shallow or sob.



As an asthmatic of 23 years, I'll second the use of a Spacer if you're going to do an MDI. Using an MDI without a spacer takes literally years of practice, and even then...when you're hurting for O2 this is difficult to do.


----------



## Christopher

Robb said:


> Anyone have a preference on hand held nebs vs nebs on a mask?
> 
> I tend to try and push my patients to let me put it on a mask for them since the majority of the time all they do is hold the neb and wave it around, spilling all the medication out of it, rather than breathing through it.
> 
> Obviously don't force them but unless they directly ask for the handheld nebulizer I just set it up on a mask and don't give them the option.



I like the mask so I can put nasal EtCO2 under it (with 3-4 L/min of flow as well).

Also as an asthmatic I feel like I'm doing less work when I have a mask on.


----------



## ThadeusJ

I'm a big supporter of MDI's over nebulizers and here's my reasoning behind it:
1) the medications are essentially "topical" in the sense that they have to reach the affected area in order to relieve symptoms and absorption into the bloodstream will bypass any therapeutic effect (although the patient will "feel" them working via increased heart rate, muscle twitching, etc);
2) in order to reach the affected airways, the particles must be as small as possible (but not too small that they will be exhaled);
3) the airways are designed to physically trap small particles such as airborne dust and bacteria that are traveling through the air (things we can't see with the naked eye);
4) the majority of the particles that are generated by a nebulizer are filtered out in the upper airway, absorbed by the mucosa and are not therapeutic and we can see them with the naked eye;
5) if you breathe them in at a fast rate, turbulent airflow increases the natural filtration of the airway and the inertia of the particles will not allow them to make all the bends in the airway (remember, there's no filter paper in the airways-think of a tornado and the centrifugal forces involved);
6) therefore, slow, deep breaths of small particles are the best way to administer inhaled particles in an efficacious manner;
7) MDI's are designed to administer small does of smaller particles only on inhalation;
8) spacers are used to capture the medication "like a cloud", to be inhaled like the only $100 cigar you are ever going to experience (slow, deep and held at end inspiration to let it marinate);
9) look at the doses you are administering: one puff of albuterol is a few um and you give, what, 2-4 puffs.  The comparable dose of nebulized is 5-10 times that.  Why is that?
10) yes, MDI's are misunderstood and people have died from not following orders.  Most people don't  take them properly.  Always use a spacer (some brands even have a whistle that tells you that you have exceeded peak inspiratory flow and medication administration is becoming inefficient).  Slow it down, take your time and concentrate on getting the dose to where it should be; to the bottom of the lungs.  If you feel it hit the back of the throat, guess what, it ain't throat medication;
11)  people often think that nebs are better because they feel relief at the end of the treatment.  20 minutes.  It still takes 20 minutes to reach the peak effect for puffers since its the same medication.  You just gave it all at once;

12) finally, some comic relief:
http://www.youtube.com/watch?v=dMAS2S51bM8


----------



## NomadicMedic

I always run a neb on a mask with an ETCO2 cannula underneath. I don't flow O2 to the cannula, I just use it to measure ETCO2. The only time I run nebs on a handheld T pipe is when they absolutely can't, will not, no freakin' way keep a mask on their face. 

And I run 'em at 8. Way more than that if its inline with CPAP.

A good way to tell if they're working is to watch the expiratory plateau of the end tidal wave form. It's very nice to see the sharkfin of air trapping turn to an even co2 release.


----------



## ThadeusJ

n7lxi said:


> A good way to tell if they're working is to watch the expiratory plateau of the end tidal wave form. It's very nice to see the sharkfin of air trapping turn to an even co2 release.



That is one excellent piece of advice, right there!


----------



## Handsome Robb

n7lxi said:


> I always run a neb on a mask with an ETCO2 cannula underneath. I don't flow O2 to the cannula, I just use it to measure ETCO2. The only time I run nebs on a handheld T pipe is when they absolutely can't, will not, no freakin' way keep a mask on their face.
> 
> And I run 'em at 8. Way more than that if its inline with CPAP.
> 
> A good way to tell if they're working is to watch the expiratory plateau of the end tidal wave form. It's very nice to see te sharkfin of air trapping turn to an even co2 release.



We, unfortunately do not have sidestream ETCO2 :-/ Our FTOs and a few others are doing a trial of them. Haven't heard anything about them making their way onto all the trucks though... I heard there were a few problems with the brand they chose. Something about them reading too high at baseline. Not sure if they sorted it out, haven't heard much more about them. 

Random excited green medic comment. I used CPAP for the first time with an inline neb for a COPDer. Worked like a charm! Probably one of the cooler things I've seen in the long time. People always said it was like a "light switch" and now I see what they were talking about!


----------



## NomadicMedic

Robb said:


> We, unfortunately do not have sidestream ETCO2 :-/ Our FTOs and a few others are doing a trial of them. Haven't heard anything about them making their way onto all the trucks though... I heard there were a few problems with the brand they chose. Something about them reading too high at baseline. Not sure if they sorted it out, haven't heard much more about them.
> 
> Random excited green medic comment. I used CPAP for the first time with an inline neb for a COPDer. Worked like a charm! Probably one of the cooler things I've seen in the long time. People always said it was like a "light switch" and now I see what they were talking about!



I'd be checking up on the status of getting it on the trucks. It's the best indicator of effective ventilatory status we have in ems. In fact, our system has made the use of nasal prong end tidal measurement a requirement in several protocols. Any patient who receives pain management, respiratory, chest pain, any priority 1 (circling the drain), CPAP and any pre-RSI. 

Of course we use it on every intubated patient as well. 

If we get in the habit of using it, we don't have to think about getting the filter line set out. It becomes automatic. 

We use the Oridian sets and have had no issues.


----------



## Tigger

Christopher said:


> As an asthmatic of 23 years, I'll second the use of a Spacer if you're going to do an MDI. Using an MDI without a spacer takes literally years of practice, and even then...when you're hurting for O2 this is difficult to do.



It has been my experience that those really hurting struggle to use an MDI even with a spacer. Most of my athletes (I can do breathing treatments for sports medicine work but not on the ambulance) I work with know when they are not going to be able effectively use an MDI, so then we go ahead and give them a neb.

Usually it's handheld since we don't really stock masks and I usually either have to make one or use one "borrowed" from a standby unit.


----------



## ThadeusJ

I would suggest that you try to use a spacer that has an attached mask or place a silicone connector onto the mouthpiece of a spacer so you can attach a cushion style BVM mask.  People often say  that they can't use a puffer because they can't inhale...which makes me wonder how the nebulized meds make it down...

By the way, they make spacers for horses since they are prone to exercise induced asthma.


----------



## Tigger

ThadeusJ said:


> I would suggest that you try to use a spacer that has an attached mask or place a silicone connector onto the mouthpiece of a spacer so you can attach a cushion style BVM mask.  People often say  that they can't use a puffer because they can't inhale...which makes me wonder how the nebulized meds make it down...
> 
> By the way, they make spacers for horses since they are prone to exercise induced asthma.



Many of them have just come off the field or ice and feel that they can't take a deep enough inhale to use it properly. After a minute or two on the neb they apparently open up enough to start "properly" using the neb.

I don't really have much of an idea of which one is more appropriate I will admit. My Athletic Trainer bosses usually give me the "it works when we do it this way, so we do it" type explanation. I'm trawling for knowledge here.


----------



## ThadeusJ

For athletes, by far the best approach is to have them take the medications long before they hit the ice/field.  I don't dispute the fact that cold, damp air of arenas contributes to exercise induced bronchoconstriction.  The monograph for Ventolin states that a "measurable improvement" can be found within 5-15 minutes, but peak effect is in 60-90 minutes, lasting 3-6 hours.  These are the results of pulmonary function studies repeated many times.  Ipratropium is longer than that but has a synergistic effect when given with albuterol.

Personally my feeling is that the vast majority of bronchodilator "success" is anecdotal, subjective and far over-relied upon. Unfortunately this has led to forum threads and social website pages dedicated to the fact that these classification of drugs are prescribed for almost every illness.  Will it change our practice?  Probably not.


----------



## Tigger

Problem cases are given nebulizer treatments prior to competition or practices that the athlete believes will likely can cause an issue. We use mostly albuterol but some athletes receive levalbuterol under the request of a team physician.

If an athlete has to stop competition because of bronchoconstriction that is not responsive to an MDI (for whatever reason, I can't make them use it properly though I do try), they are held out for at least 20 minutes to give the medication a bit more time to work.

I've dealt with an athlete with fairly severe exercised induced asthma and Thalassemia. For me he can be a fairly worrying case during an asthma exacerbation. He looks like crap, becomes quite lethargic, sometimes has blue lips and often has a pulse oximetry reading in the low 80s. He usually responds quite well to a nebulizer treatment and perks up in only a few minutes.


----------



## mycrofft

I am enjoying the low degree of armchair quarterbacking here.

I was treating a population of people with issues relating to drug abuse (including albuteral), crack and crank smokers, the offspring of crank and crack smokers, tobacco smokers (but we were a nonsmoking facility, ha), ER-as-primary care, medication sharers/self-prescibers, and some really bad asthmatics as well.

1. Most had some of the MDI routine right, but many had bad timing (or rhythm). "Blipping" the canister and squirting it four or five time in full-auto was not enthusing. One old guy did it 13 times; when I asked him how many times, he said two.

2. Non-asthmatics using them as a pre-basketball performance enhancer. Not saying it worked, and some folks I think had bad effects from this, but they used it for that.

3. We had the $20 Transformers-like folding spacers. but found proper technique and one segment of blue respiratory tubing did as well for adults. Poor technique left powder inside the tube and we could point to it as a teaching tool for better technique.

4. Did you know you can spray albuteral or its older cousins on cigarettes and get a buzz?

5. When I started teaching and administering inhalers (1987) you had to hold your mouth off the mouthpiece. Now most if not all inhalers have an air gap between the canister and the handpiece wall allowing enough air to pass with your mouth closed on it *IF* you have pretty decent inspiratory effort.

BTW, we had personalized inhalers in a big wall organizer, and wasted out dozens of seemingly full ones each month; checking the books, those pt's stopped asking for them after the first or second time because we would not give it if not needed, and we would not let them machine-gun doses as they were used to. They did just fine. Stopping smoking of _*everything*_ helped, but we wasted hundreds of dollars and man-hours each month.


----------



## MSDeltaFlt

Here's the deal regarding optimal flow for nebs.  You do get the best results at 6-8L/min.  Some have been known to give st 10 L/min.  However, at that rate the medication is baffled more in to smaller particles and sometimes the smaller particles can actually irritate he distal bronchioles exacerbating the wheeze.  So 6-8.  No more.


----------



## Clare

As others have said, 6-8 lpm here and if the patient has mild to moderate asthma and an MDI that is clean and usable then preference should be given to using their own medicines. although in theory if they have called an ambulance then their own medicine is not working ...


----------



## NomadicMedic

I've removed the off topic posts. Let's try to keep the discussions focused on the topic.


----------



## TomB

It's almost like being in kindergarten! Thanks, n7lxi.


----------

