Administration of bronchodilators for pulmonary edema?

Melclin said:

Interesting (but learn to proof read you knob ). I've never heard of the whole bronchospasmic auto-peep thing, and not yet (in my many long years in ambulance) encountered the implications of getting rid of it. Is there more info on it kicking around?

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Sorry mate, can't all be academics like yourself

Mostly we see auto PEEP in COPD'ers, in this case it is achieved by their pursed lip breathing, but you may already know it as intrinsic PEEP.

You'll know it when you give salbutamol and the auto PEEP is what was keeping them going, they get crook really quick :wacko:

I don't know if I missed anything but for cardiogenic pulmonary oedema, we give
GTN, frusemide, morphine, cpap and only give salbutamol if bronchospasm is present but never as a first line drug of choice.

Corky said:

Why would you not first treat the cause of the wheezing with NTG and CPAP. Instead of simply treating the wheezing. Studies show greater then 50% prehospital pulmonary edema wheezing AKA Cardiac Asthma is treated inappropriately with bronchodilators

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Corky,
I am curious which studies you are referring to. I personally have always been interested in this conversation and would love to look at those if you don't mind sharing. Thanks so much.

Stay Safe,
NewEnglandEVE

Although this may have been answered already by PM, a similar figure can be found in Bronchodilator therapy in acute decompensated heart failure patients without a history of chronic obstructive pulmonary disease.. It used registry data, and found that 20% of the CHF patients who received beta-agonists had no history of CHF. They also found a higher rate of intubation in that subset.

A different study (Cardiac asthma in elderly patients: incidence, clinical presentation and outcome.) was only done in elderly patients who presented in CHF, and found that about 1/3 of them had wheezing with their CHF episode.

I'm not sure about the 50% number mentioned above, though. Best I could find!

This thread motivated me to put together a small review, going over the most relevant clinical evidence I could find about wheezing, bronchodilators, and CHF. Check it out, if your interest in the topic isn't already exhausted!

"All that wheezes" - CHF and albuterol

KellyBracket said:

This thread motivated me to put together a small review, going over the most relevant clinical evidence I could find about wheezing, bronchodilators, and CHF. Check it out, if your interest in the topic isn't already exhausted!

"All that wheezes" - CHF and albuterol

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Now that was an interesting read. Thank you for putting that together! Bookmarked it.

Methods
We conducted an analysis of the Acute Decompensated Heart Failure National Registry Emergency Module registry of patients with a principal discharge diagnosis of acute decompensated heart failure enrolled at 76 academic or community EDs. Dichotomous outcomes (mortality, ED discharges, ICU admission, ED IV vasodilator use, new dialysis, ED or in patient endotracheal intubation, ED BiPAP, and asymptomatic at discharge) in patients without a history of chronic obstructive pulmonary disease who were given bronchodilators were compared to those who were not given bronchodilators using logistic regression; odds ratios (ORs) and 95% confidence intervals (CIs) were calculated; and propensity score adjustments were made.

Results
Of the 10,978 patients enrolled, 7299 (66.5%) did not have a history of chronic obstructive pulmonary disease. Bronchodilators were administered by the EMS or in the ED to 2317 (21%) patients. Patients without chronic obstructive pulmonary disease given bronchodilators were more likely to receive ED IV vasodilators (28.4% vs. 16.9%; propensity adjusted OR 1.40 [95% CI 1.18-1.67]) and in-patient mechanical ventilation (6.0% vs. 2.4%; propensity adjusted OR 1.69 [95% CI 1.21-2.37]) than patients without chronic obstructive pulmonary disease who were not given bronchodilators. Hospital mortality in patients without chronic obstructive pulmonary disease was similar regardless of bronchodilator treatment (3.4% vs. 2.6%, propensity adjusted OR 1.02 [95% CI 0.67, 1.56]).

Conclusion
Many acute decompensated heart failure patients without a history of chronic obstructive pulmonary disease receive inhaled bronchodilators. Bronchodilator use was associated with a greater need for aggressive interventions and monitoring, and this may reflect an adverse effect of bronchodilators or it may be a marker for patients with more severe disease.

I am a Respiratory Therapist on a crusade to set the healthcare community straight about the over use of bronchodilators. "
our fluid won't help yours" It's our catch phrase for treating CHF with albuterol. BIPAP/CPAP, Lasix, are the way to go. If you see improvement by using a CPAP/ bronchodilator combo, I can assure you, the albuterol isn't doing anything. In fact, I observe 99.9% of my patients, if not already doing so, develop an audible, upper airway wheeze. And by the way..... if you can hear the wheeze (hence audible) it's not a wheeze. A wheeze is never audible. If you can hear it, it's in the upper airway and what you hear in the lungs is being heard from the throat over the breath sounds. If you can hear it, start thinking fluid ie. pulmonary edema, pneumonia. This is forced exhalation. You'll also notice belly breathing. They are actively forcing out air. Giving Albuterol is a waste of our time and a waste of the patient's time. We need to address the distress they are in and assist their breathing with BIPAP. Aid in pushing out the fluid with CPAP. Please don't add a useless treatment to our workload. I realize this rant would be better served on an MD page. I haven't found one yet. Believe me, I'm looking. I had a patient with a BNP of 1000, BUN and Creat sky high, basically renal failure, get admitted with a diagnosis of pneumonia (with a clear chest xray although it clearly showed edema), and COPD exacerbation. The admitting hospitalist decided to treat with steroids and bronchodilators. Unbelievable. After 17 years of doing this, I am disgusted with the lack of knowledge on this subject. So I will sing it from the rooftops. No bronchodilators for CHF! For the love of GOD! PLEASE!

Credit for the study I posted above:
Supervising editors: Rita K. Cydulka, MD, MS; Michael L. Callaham, MD

Author contributions: AJS and WFP conceived the study. The registry was designed by all authors. Funding was obtained by all authors from Scioc Inc. Recruitment of participating centers and patients was performed by AJS, CE, DMC, JTH, JDK, JEH, RS, CCL, and WFP. JW and LK provided statistical advice and analyzed the data. AJS supervised the data oversight. AJS drafted the article, and all authors contributed substantially to its revision. AJS takes responsibility for the paper as a whole.

tmarie said:

I am a Respiratory Therapist on a crusade to set the healthcare community straight about the over use of bronchodilators. "

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With respect, do you think this topic is important enough to warrant the amount of effort you're putting into it?