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Wednesday, November 28, 2007

Rescue bronchodilators: Here are my unfettered answers to all of your questions about them

The following are some questions real patients have asked me recently regarding rescue bronchodilators. The answers here are my humble personal and professional opinions and nothing more.

Keep in mind that your doctor might disagree with me, and that's fine. He can overrule me whenever he wants. But, the answers here are based not just on my 10 years as an RT, but over 30 years as a chronic asthmatic who's abused more than his share of inhalers and lived to tell about it.

Q) What is the recommended dose for albuterol

A) Every 4-6 hours as needed ( no surprise here.)

Q) What if I need it more often than that

A) For most patients, I'd recommend seeing your doctor if you need it more often than every 4-6 hours, because it's a sign that your asthma or COPD is getting worse and needs to be better controlled. However, it's a relatively safe medicine, and some doctors prescribe it to be used as needed for some chronic patients.

Q) What do you think of a doctor ordering Albuterol MDI every four hours?

A) Albuterol is typically a rescue medicine, and should be taken when you are short-of-breath (SOB) due to bronchospasm. It's not going to hurt if you use it more often than when you need it, but I don't see why it would be beneficial.

Q) My doctor says Albuterol will work to prevent an asthma attack, so I should use it every four hours all day. Is this true?

A) I was taught when I was kid to take my Albuterol before I took gym class, and I did. However, it never prevented me from getting SOB. It did, however, make me feel better once I was SOB. So to answer this from my own personal experience, I'd have to say no; Albuterol does not prevent asthma symptoms. However, you can try it to see if it works for you.

There are many doctors who do believe it can be used as a preventative drug. Not only that, it states this on the Albuterol package insert. However, if it is deemed necessary that preventative medicines be taken to prevent an asthma attack, there are far more effective medicines to be using, such as Vanceril, Flovent, Atrovent, Cromolyn, Advair, etc. (this will be discussed in a later post.)

Q. I've had an Albuterol inhaler for the past 3 years. Sometimes I use it more that 10 times in a day, which is more than the prescribed frequency of every 4-6 hours. Can I use Albuterol this much and feel safe?

A. I'm treading on thin water here, but I will say yes. I find from my own personal experience as a former Albuterol abuser, and professional experience giving treatments, that Albuterol is a very safe medicine. The most common side effect is that it might make you jittery, which you probably already know if you've done it before. If you were going to have a negative reaction to the medicine, like an increase in heart rate, it would have happened already.

However, if you have other medical issues besides just COPD or Asthma, then I'd be really cautious of using too much Ventolin. I'd recommend consulting your doctor if you need to do this. Personally, though, I still think Albuterol is safe and effective in most situations where real bronchospasm is the issue.

Q. But my doctor has me on all the right preventative medicines and I'm still finding myself going through an inhaler a week. Will this have long term implicaitons on my life span?

A. I asked my doctor that exact question when I was a kid, and he told me using my inhaler was better than suffering and chancing an anoxic episode. If you absolutely have no choice than to use your inhaler more than every 4-6 hours, make sure your doctor knows about this. Chances are, he will still renew your prescription because he doesn't want you to suffer. However, he may also continue to try to adjust your other medicines to make your life easier. Sometimes, however, as in some cases of COPD or end stage COPD, this is not possible.

Let me answer this question this way. I went through an inhaler a week from the time I was 13 or 14 until about a year ago when I started taking Advair. That was 25 years. I'm getting along just fine now. Will my Albuterol abuse cut some years off the end of my life? Well, nobody really knows. Albuterol has only been around since 1987. Personally, I doubt it will.

Q. My doctor prescribed Atrovent as my rescue inhaler, what do you think of that? Should I be worried if I use it more than four times a day, because I do?

A. Atrovent is not a rescue inhaler. Atrovent takes about 20-30 minutes to work, while Albuterol, idealy, should work almost instantaneously for bronchospasm. Then again, if Atrovent works for you, then that's great. If it isn't, then I'd talk to your doctor about getting an Albuterol inhaler.

Q. Am I safe using Atrovent more often than every four hours, because I do?

A. I don't see what it would hurt. When I was in school ten years ago we were taught never to use Atrovent more often than Q4. However, some new research shows that addtitional Atrovent during an exacerbation does benefit patients. If Atrovent is working for you as a rescue drug, all the power to you. However, if you continue to be short-of-breath, you should talk to your doctor about getting an Albuterol inhaler or (ideally) adjusting your preventative medications.

Q. Can I use my Combivent more than every 4 hours?

A. Again, I don't think it would hurt you, but it's not necessary. Technically speaking, the Atrovent in this medicine shouldn't need to be taken more than every four hours. If you need to use Combivent more than every four hours, then you should talk to your doctor and get an Albuterol inhaler. You can then use your Combivent four times a day, and Albuterol in between if you get short-of-breath. (and still I'd only recommend this only if other preventative medicines weren't working.)

Q. Do you think Xoponex is better than Albuterol?

A. No. I have never noticed a difference. Original studies claimed that Xoponex was stronger than Albuterol, but I've never noticed that to be true in my real life experiences with the two drugs. Not only that, I don't think the claim that Xoponex has fewer side effects than Albuterol is true either. Recent studies have confirmed this.

However, if you have experienced cardiac side effects, or excess jitteriness or nervousness, then you might be a candidate for a trial of Xoponex, if you want to flip the bill: Xoponex costs 5-10 times more than Albuterol.

Q. What if I go through an inhaler a week?

A. Every patient is different. Do you have end stage COPD? If so, you have to do what you need to do. Do you have asthma? Then perhaps you could trial Advair. Advair worked like a miracle drug for me. I went from one inhaler a week and 600mg of theophylin twice a day down to two 300mg pills a week and 4 puffs of Albuterol a day after being on Advair 9 months.

You and your doctor have to find what works best for you. If there is no other alternative, then an inhaler a week might be the best solution.

I meet albuterol abusers at work all the time, and the majority of them are end-stage COPD patients. However, on occasion, I have met a fellow asthmatic who abuses too. Most of them think they are the only one. And, most of them think they are doing this furtively without their doctor's knowing.

Many times I walk into a patients room to give a breathing treatment and find that MDI hidden under the pillow, a sign of a true rescue inhaler abuser.


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Anonymous said...

Dude... You might want to rethink your answers on using albuterol... It should be as needed in asthmatics and generally if used more than twice a week (excluding EIA) your asthma is out of control and you are put into a bracket that is at a higher risk of death from asthma. Patients should always tell there doctor if using albuterol more than twice a week on a regular basis and their doctor should step them up on their maintenance medications. It's all in the asthma guidelines.

Freadom said...

No, what you read is what I meant. Sure, I think patients should use good preventative medicines, as these will allow most asthmatics to live normal lives.

However, there are still going to be people who will need to use a rescue inhaler more than twice a day despite the best preventative routine.

I am one of these patients. Before I went to the RT program I thought I was the only one. I have met many like me on the job. You probably do too.

None of these patients want to go to the hospital every time they have a bronchospasm, especially when they know 2 puffs and they are cured. And most doctors know the patients who do this. I don't keep any secrets from my doctor.

You can follow the asthma guidelines on most patients, but sometimes you have to step outside the boundries to take care of the most severe asthmatics -- like me.

We step out of the boundries every time we do continuous Ventolin treatments. That's not something that's recommended, but we know it works sometimes, and it's relatively safe.

My doctors have controlled my asthma for 30 years this way, and I live a normal life. I jog 3 miles a day and haven't made one trip to the ER as a patient in 10 years.

I wrote this post because I know there are many people like me, and I wanted to let them know that it's okay. They aren't going to die just because they use Ventolin more than recommended, or Atrovent too for that matter.

I've had this discussion many times with my doctor, especially since I became an RT.

Anonymous said...

We don't step out of the bounderies when we use continuos nebs. There is plenty of research out there to support it's use. It is actually supported in the asthma guidelines. I'm not trying to pick on you or anything but the best advice any Therapist can give patients is that they should at least give the guidelines a try before they decide they can just start using albuterol as a crutch.

If you use albuterol that much you should actually be taking systemic steroids as a last resort.

Look it up sometime.

Freadom said...

I agree with you, people should follow the guidelines. However, you must keep in mind that while medicine is based on science, it's actually an art: you must treat each patient independently. And guidelines are just that: guidelines.

sandigram said...

Take this from me, when your lungs are shot, like mine, you do what you have to do. I was diagnosed with emphysema 10 years ago, had bilateral lvrs in 1999. I have been intubated 4 times, not counting surgery, and I am puffing on my inhaler every couple hours with no ill effects. This is besides, xopenex nebs, theo-dur, advair and spiriva. so I have to agree it won't harm you.

Freadom said...

It's very safe. And no doctor in his right mind is going to take it away from you, as no Dr. has ever tried to take mine away.