I have just spent 32 hours at an Asthma educator conference in SF. Just when you learn to play the game they change the rules and all the meds. However, the good news is we are saving the ozone by going to HFA as the propellant in the MDIs.
http://www.asthmaeducators.org/
The phase out of CFCs in MDI is from the Clean Air Act and an international environmental treaty, the Montreal Protocol on Substances that Deplete the Ozone Layer.
Next month I get to learn all about the new meds and treatment plans for COPD. Lucky for me, many of the changes in EMS are also within my respiratory world such as transport vents, ETCO2 and interfacility issues for the technology and the meds.
I bet I get more CEUs this year than Rid.
A few news worthy items:
Combivent MDI still has been unable to reformulate from CFC and still has a soy lecithin base. This means patients with sensitivity to soybean products and possibly peanuts can have a reaction.
Atovent MDI is HFA so this is no longer an issue.
MaxAir will be the exception to the CFC ban...for now. It is a breath activated inhaler.
http://www.gracewaypharma.com/pdf/maxair_letter.pdf
DO NOT test how full an MDI canister is by floating it in water.
Many of the new MDIs now have counters on them.
There is no generic Albuterol at this time. (I am capitalizing Albuterol out of respect for it.) If you see a generic Albuterol canister (usually white) still in action, check the expiration date.
People will complain about the different in their new HFA inhalers because they have been used to the CFC propellant delivering a slightly cooler spray at a much faster speed.
The "2 finger widths from Open Mouth" technique is no longer advised with the new HFA MDIs. Closed mouth is acceptable and aerochamber is preferred.
Here's a great website, especially under the section that says "EDUCATION".
http://www.thoracic.org/
Here's another one with the new guidelines for Asthma, EPR3. EPR2 is still in effect but not for long. Right now the only thing that may change for EMS and EDs is the number of rescue puffs by MDI that is given in those areas.
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
Because a person says they don't have asthma may mean they haven't been diagnosed with asthma....yet. They may not have been tested and may have been treated for something else. Spirometry along with excellent history notes will ensure the proper diagnosis. This is, of course, in response to other symptoms which may not be the typical asthma ones taught in EMS programs.
Unfortunately a good hx for asthma is rarely taken prehospital or in the ED. As EMTs and Paramedics, if you are in the patient's home, you can spot different allergens that may be triggering some response in the patient's airways. Was the home wall to wall carpeted? Pets? Smokers? Dusty environment? Occupation? Family history?
Meds? Was the patient being treated for sinusitis? Rhinitis? GERD? Overweight? OSA?
Those same questions apply to the pediatric population including the ones concerning gastric reflux, obesity and OSA.
Now for this scenario in the original post:
Nursing home?
How old was the patient?
Did the patient have a good SpO2 on a 4 (?) L neb? If so, why the 15 L NRBM? Usually an asthmatic won't desat until they are decompensating.
What were the
breath sounds pre Albuterol and when the decision to remove the neb was made?
HR pre and post?
Was the 2nd BP taken while she was coughing and gagging?
Where both BPs manual or machine?
Did the nurse say what the pt's normal BP was?
What meds were on the patient's list?
Beta Blockers?
Medical history?
Did this patient have history of COPD?
Did the nurse take a temp? Rectally?
Was the patient responsive to verbal or any stimuli?
Did she have a gastric tube or had she just eaten?
Did she cough on request?
Nasotracheal suction or yankuer (tonsil tip) orally?
Recurrent PNA (pneumonia) especially due to aspiration?
Many times the NH patient that has had chronic aspiration issues will be on Albuterol nebs because someone will hear "wheezes" from the aspirated fluid which can also include saliva in CVA pts who have impaired swallow. The wheezes may also be from an inflammatory process or hyper-reactivity due to the irritating apirated secretions. If the patient was recently in the hospital for PNA, the Albuterol sometimes gets carried over on the transfer orders without anyone questioning it. And, sometimes albuterol gets ordered for everyone just because. Even in some EDs, it is used to give the physician a few minutes to get his/her plan of action in place or to fill a void between tests so the patient and family believes something is being done.
Beta-2 agonists are used for reasons other than asthma, but not darn many unless you are going "off-label"*.
We've taken albuteral (and Alupent) MDI's out of dead people's hands. The pt's had cardiac issues, the albuteral made them feel more breathless, more albuteral,more breathless, more------------------flatline.
Who prescribed the MDI inhalers? For what? What were the cardiac issues? Unfortunately for many respiratory patients, especially COPD, cardiac issues often come with the territory. Long term COPDers may have pulmonary hypertension and Cor pulmonale (enlargement and strain on the right side of the heart). They may become prone to supraventricular arrhythmias also.
Even in the much debated CHF and Albuterol threads, Albuterol is frowned on if the patient is have an MI. It is still given occasionally to a CHF pt without evidence of an acute MI if they have a history of COPD.
A quick search found 1 case study with Albuterol suspected of being the cause of an MI in an 84 y/o. However, the dose was 5 mg with 500 ug Atrovent q2 hours x 6 treatments.
http://www.theannals.com/cgi/content/abstract/38/12/2045
We could also get into a lengthy discussion about Albuterol and hyperkalemia but not on this thread.
Off label?
Exercise induced asthma (EIA) is fairly common and albuterol taken 15 minutes prior to exercise is highly recommended. Some athletes (and weekend warriors) don't like to consider themselves "Asthmatic" since their wheezing/SOB only occurs during exercise.
As far as it being performance enhancing, that is debatable. If your VO2 max increases after taking Albuterol, then yes it is performance enhancing. If you have been using someone's albuterol and felt you performed like you never have before, then yes
your performance has, in a sense, been enhanced. You may also have been having bronchocontriction as a result of EIA in previous workouts and didn't know it. However, your physician may want to see your performance and check for EIA in the Pulmonary Lab before giving you your own prescription for Albuterol. Usually, if you have no bronchospastic component, Albuterol will not do much for you except for the side effects.
Many people become accustomed to be short of breath while blaming it on be out of shape or "deconditioned". Some may actually have some bronchospastic airways if put to the test via spirometry and treadmill.
As far as death, Asthma deaths are becoming more common. Albuterol by itself is not going to keep you out of trouble. If you have been non-compliant with your maintenance meds and ignore the warning signs, then albuterol may be fighting a tough battle. If the MDI was used incorrectly, not shaking it to mix, technique sucks improperly, expired or empty, then the albuterol MDI ain't gonna work.
Now that there are so many different MDIs on the market, many patients (and healthcare professionals) are going to be confused. Keep an eye out for what inhaler they were actually doing to break their difficulty breathing. It may not be a rescue inhaler. It could be a corticosteroid, long acting beta-agonist (LABA) or a combination of the two such as Advair or Symbicort. These could present as a problem if too much is taken and should be noted to the ED staff. Advair does have a counter on it.
