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Thursday, November 1, 2007

Kid Albuterol season opens today

With the start of school comes the inevitable baby with cold, flu or Respiratory Syncytial Virus (RSV). And when doctors see these patients with their congested lungs and runny nose, a page to the respiratory therapist for a breathing treatment is eminent.

Amid my run of 10 p.m. breathing treatments tonight, I was called to the ER twice to give a treatment to 4-month-old babies with high respiratory rates, stuffy heads and snotty noses. I noticed no difference with either of the treatments.

"Oh, much better," the nurse said as I was finishing up the second treatment. "He should be able to go home now as soon as Rick does an RSV swab."

What evidence she used to come to that conclusion I had no idea.

Over thinking things as I usually do, I often wonder if breathing treatments even get down into a baby's little lungs. The particle size of medicines in the mist of a treatment is 5 microns, and that's the perfect size to fit into the bronchioles of an adult patient. But baby lungs are smaller than an adults, so how does the Ventolin fit in there.

I looked on the insert of a box of Albuterol, and it reads: " Albuterol... is indicated for the relief of bronchospasm in patients 2 years of age and older with reversible obstructive airway disease and acute attacks of bronchospasm... The safety and effectiveness of Albuterol... in children below 2 years of age have not been established."

Obviously they were thinking the same thing. Regardless, Albuterol is the treatment of choice for stuffy and uncomfortable children under 2.

One study I read a few years back indicated that suctioning the airway was more effective than breathing treatments in treating patients with RSV. A breathing treatment may be attempted once, but if no improvement is observed, then no further treatments are indicated. In this case, I'd simply make this patient Q4 PRN.

Since these new studies and recommendations came out, not only do we give routine breathing treatments Q4, but we also use BBG nasal aspirators, otherwise known as booger be gones. That's progress I suppose.

Reasearch by American Family physician must have shown treatments do little for RSV patients, since their clinical practice guidelines state, "routine use of bronchodilators is not recommended.", and, "Studies also have not shown that bronchodilators have a long-term impact on the disease course."

The Cincinnati Children's Hospital Medical Center came to the same conclusion. Their guidelines also call for suctioning often.

Then again, everybody is subject to their own opinion. And, as has always been the case in the medical field, trying something as safe as a bronchodilator is better than doing nothing at all.

I know that there are certain qualifications that have to be met in order for insurance to pay, and breathing treatments for diagnosis of RSV is one of the qualifications. I personally think that's a puerile policy, but that's the way it is. Quite often, other than to make the family think we are doing something, this is the only reason I think we are doing most of these treatments. And this is unfortunate for me, because it burns me out, and for my asthma and COPD patients of whom are more deserving of my Albuterol Ampules.

Likewise, upon assessing hundreds of these children, I rarely notice a change in lung sounds, nor any improvement in retractions or nasal flaring if evident. There are obviously exceptions to the rule (baby's with real bronchospasms), but I find this to be true in most cases.

In all my research, I have never come across a study that conclusively confirms treatments do anything for these kids. I wonder if doctors are privy to esoteric knowledge, are grasping at old beliefs, or are simply ordering treatments because of the philosophy, "if it's pulmonary it should be treated as bronchospasm."

There is one other theory I have on the matter, and that is that the doctor orders Q4 ATC for no better reason than to make sure a respiratory therapist is checking on the patient. Some doctors, if this theory is accurate, feel more comfortable sleeping at home when they know their patients are in the high qualified and well respected care of the respiratory therapist.


Djanvk said...

Great writeup very informative. I looked into this RVS vs Neb tx's a couple years ago and found nothing stating that Albuterol helps. Why did I look this up, I had the same though, there is no change after this tx. What I did read is that Racemic Epi gives the most relief for RSV, but I never see anyone using it.

Anonymous said...

It drives me bananas when docs write for Albuterol when there is no bronchospasm. Very well written!