Albuterol for CHF

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Hi All,

I just finished my internship last week and I need to admit, I did not get as many resp distress calls as I would have liked. Consequently, I am still a little nervous at the thought of how I would treat somebody in extremis with a problem such as CHF.

I know the basics of definitely giving high flow O2, sitting the patient up, IV access, NTG, Lasix, and possibly even MS. I have worked with different medics and seen different types of treatments. What confuses me is when/whether to give Albuterol. My precepter told me that an indication is if the pt sounds "tight" and is not moving much air. But, trading high flow O2 via NRB which provides 90% - 100% O2 for a HEB @ 8LPM which I would assume provides less doesn't seem like stronger treatment. Of course, there is the option of giving an Inline Neb Albuterol Tx through a BVM, but that treatment option seems to be reserved for somebody on the cusps of extreme distress or failure.

I've also worked with some medics who say that they would never give Albuterol, because as they explain it, makes the container bigger and more suspeptible for more edema.

I'm curious what you all think (and do)...?
 
It depends. I'm not a big fan of giving Alb for CHF, but I'm not against it. You need to get good breath sound assessment before you give it. Listen to where the rales stop, AND how much clear air exchange you have with or without wheeze, AND where is the wheeze? If their lungs are full, don't. Why give a fluid (which is what the neb mist is) in a container that is already chock full of fluid?!? It makes no sense to me.

Plus, 15 l/m NRM on ANYBODY is resp distress is not receiving that 90% - 100%. Can't get 100% anyway. Impossible. So, yes. A neb is much much less FiO2.

So, follow your protocols... should be something like this:
1. 15 l/m NRM
2. NTG (may need to call med control if the 3-4 prays don't cut it)
3. Lasix (not that fast if just a few blocks from ER)
4. Neb (only if wheezing more than crackling)

RidRyder and VentMedic can give you actual emperical data. I'm just a philosophical medic myself.

But that's my two cents
 
It is my understanding that when the Maryland Medical Protocols are updated later this year, albuterol will be removed from the CHF protocol.
 
follow you protocols. If you have an option, do what you feel comfortable doing and let the ER take care of the rest.
 
Think about what's going on with the patient and what the different drugs available do. When you really think about it, I think you'll see that albuterol is more of a last ditch effort when the standard treatment isn't working or maybe isn't working well enough. Another thing i've heard of being done (but haven't attempted it myself) is to use a bvm to create cpap.
 
Chf

I've never been impressed with using albuterol for CHF...primarily due to the increase the HR in someone who's in heart failure. Our protocols allow NTG, lasix and morphine...and now with the availability of CPAP and RSI (if they get tired or I feel it's needed), I see albuterol being phased out of the CHF protocols in the near future.
 
firecoins said:
follow you protocols. If you have an option, do what you feel comfortable doing and let the ER take care of the rest.
Click to expand...

What does that mean? ..

Albuterol is not recommended in CHF and in some do not recommend because of the work load (tachycardia) may increase infarct size.

CPAP is one of the best tools that have been introduced within the last few years. Along with administration of Nitrates in reducing the preload factor reduction for RSI have dropped almost in half, as well as ICU admissions. Personally, I am no longer a big fan of Morphine Sulfate, as studies are demonstrating some damage to the pathways from the Morphine. More needs to be studied, but remember the major cause is pump failure.

R/r 911
 
Very recent article:

http://www.rtmagazine.com/reuters_article.asp?id=20080214clin015.html

Acute Heart Failure Patients Without COPD Often Given Bronchodilator Therapy
by Will Boggs, MD

Last Updated: 2008-02-14 9:57:29 -0400 (Reuters Health)

NEW YORK (Reuters Health) - Many patients seen in the emergency department with acutely decompensated heart failure receive bronchodilator therapy for dyspnea even though they have no history of chronic obstructive pulmonary disease (COPD), according to a report in the January issue of the Annals of Emergency Medicine.

"Do not just throw in the 'kitchen sink' (i.e., bronchodilators) to all dyspneic patients, since this might be harmful," Dr. Adam J. Singer advised in comments to Reuters Health. "Careful thought and judgment should be made in each individual case."
Click to expand...


This is based on the original article in the Annals of Emergency Medicine, January 2008 issue
http://www.annemergmed.com/article/S0196-0644(07)00450-7/abstract
Bronchodilator Therapy in Acute Decompensated Heart Failure Patients Without a History of Chronic Obstructive Pulmonary Disease
Study objective
Inhaled bronchodilators are often used in the emergency department (ED) before a definitive diagnosis is made. We evaluated the association between inhaled bronchodilators and outcomes in acute decompensated heart failure patients without chronic obstructive pulmonary disease.
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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.
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Thoughts

I would put the pt on a nasal capnography and look at the wave form, and CPAP would be my first treatment of choice.

Before nitro, I would have to run a 12 lead and look for anything that would contraindicate its use, as well as anything that may be going on.
 
firecoins said:
It means follow the protocols which in some cases give options of several meds.
Click to expand...

I think the problem is that when providers state "follow your local protocols," they think that such protocols are a cook book where each step has to be completed. That, in most places (including your area) isn't true though. Just because you (generic "you") can give something doesn't necessarily mean you should do something. An example of a policy like this could be seen from the Westchester REMAC [one of the things I like about internet forums is seeing how other areas are organized] protocols.

CLINICAL JUDGEMENT
Protocols are treatment algorithms that should be used in conjunction with GOOD CLINICAL JUDGEMENT. [italics added, capitalization was not] Protocols should be considered as the “models” by which all patients should be treated. Protocols are guidelines for non-physicians to administer emergency care in specific situations. Since patients do not always fit into a rigid formula approach, situations may occur which do not fit into these protocols. For patients who do not fit into a rigid formula approach, or where there is no existing protocol and a clear need for Advanced Life Support exists, the paramedic shall initiate appropriate therapy and contact Medical Control in order to differentiate the most emergent clinical problem and define the most suitable therapy. At that time, the Medical Control physician shall order the most appropriate treatment within the paramedic’s scope of practice as defined by their level of training, certification, and regional protocols.
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page 6
http://www.wremsco.org/REMAC_PROTOCOL_DOCs/2003_Paramedic_into(pg1-11).pdf
PDF warning
 
firecoins said:
It means follow the protocols which in some cases give options of several meds.
Click to expand...

Personally, I don't treat protocols, I treat the illness; but I gather the intent.

R/r 911
 
For hypertensive CHF, hand bag or primitive CPAP, nitrates, sl Q 2-5 minutes, back off when you get a 10% drop in systolic pressure. (either # of sprays or timing of single sprays)


Treat the problem, which is hydrostatic in CHF as apposed to bronchonstriction in COPD.

How many times has this been hashed out?
 
We actually just talked about heart failure in class yesterday. It was pretty interesting.

From what we were told, the problem you are dealing with in left-side heart failure is that because the pump is not working properly, fluid is backing up into the lungs. The problem with the pump can be caused by a variety of things, but basically amounts to the inability to move the fluid in an appropriate manner. The system essentially is loosing it's prime.

By giving albuterol to these patients, you dilate out the lungs, making the container bigger, thus, further depleting the amount of fluid available to the system. In turn, this increases cardiac workload, putting the already struggling pump under even more stress to attempt to keep up. It's a loosing battle for the heart.

As the problem gets worse, it can lead to right-side failure as well. This is when we begin to see peripheral edema, or third spacing of fluid into the extremeties. We were told that pre-hospitally, the only reason this is of importance to us is that it tells us that fluid is "leaking" out of the "pipes".

The best thing we can do for these patients is make the container smaller through the use of nitro. By closing the container, less fluid is required to maintain the prime within the pump. Cardiac workload is reduced.

In the past, my instructor told us they had been taught to with hold fluid but now even that is coming into question. While on the surface, the problem appears to be fluid overload, because alot of it has been third spaced, the amount of fluid being maintained within the system is actually depleted. When we drop these patients off in the ER, she told us, they actually make them worse before they can make them better. They do give these patients fluid in order to improve the prime in the pump, again, to reduce cardiac workload.

We were told that the only time albuterol would really be of much help is in a patient that has a history of both COPD and CHF and you can't tell which one is most likely causing the problem because they are moving no air at all. Then, giving the albuterol hopefully will open them up enough to hear something, and then you can determine if what you are hearing is wheezes or wet. You can then decide which road you need to go down to treat your patient.

It all goes back to understanding preload, afterload, and what exactly is happening during failure. (And if I don't have any of this quite right, please feel free to correct me.)
 
Albuterol doesn't make the lungs bigger. It relaxes the smooth muscles of bronchial airways and does that only if they need dilating.

However:

Albuterol is a direct-acting β2-agonist. Direct stimulation of the α- and β-adrenergic receptors can produce sympathomimetic effects.

The mechanisms of sympathomimetic drugs are to act as catecholamine synthesis precursors, norepinephrine transporter blockade, adrenergic receptor agonism, inhibition of epinephrine and norepinephrine metabolism and/or cholinergic inhibition. Sympathomimetic agents have a direct positive chronotropic effect on heart rate and may cause hypokalemia, even when administered by inhalation. This can lead to arrhythmias. CHF patients may already have many underlying conditions such as A-Fib, cor pulmonale and pulmonary hypertension which can be exacerbated.

Sidenote: Albuterol is used to treat hyperkalemia initially until definitive treatment can be started. However it takes high doses at 15 to 20 mg given over a very rapid period of time. It is usually given in the 0.5% concentration undiluted in a Breath Activated Nebulizer (BAN).

Sidenote: Ephedrine has indirect action on the adrenergic receptor system.

When pts are profoundly third spacing, CPAP must be used cautiously. In the hospital setting we may try to hold off until fluids and pressors are hanging to support any drop in BP as intrathoracic pressure increases.
 
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bonedog said:
How many times has this been hashed out?
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Well, although I do believe that there still thousands of Paramedics fail to manage and understand CHF adequately, research has found that patients with pulmonary edema are more prone to having a hyper-reactive airway with broncho-constriction. Thus, this question and debate is still valid.
 
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