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Friday, July 30, 2010

Continuous breathing treatments???

You see this done often: a breathing treatment with Albuterol, or even Albuterol plus Atrovent, and occasionally with Xopenex, for a continuous run of 2 plus treatments for up to an hour, or even 24 hours.

Well, I have never done a treatment for an entire day, yet I've heard of it by other therapists from other hospitals. The question of the day is: do continuous treatments do any good?

I've always been of the belief that three continuous treatments and you're out. By this point, those beta adrenergic receptor cells have to be saturated. And, usually, if you're going to see a patient's lungs open up, it'll be before that 4th treatment is started.

Another question I'd be willing to ask is: How long does an Albuterol microbial sit on a beta 2 receptor cell. If it's for less than 15 minutes, then I'd say go for the continuous. Yet, since most recipes for Albuterol say the medicine works for 4-6 hours, I'm willing to surmise that's about how long Albuterol lasts on the B2 cells.

Therefore, I'd say that if you're going to give a continuous treatment, I'd give up to three and then I'd wait at least a half hour before giving another. Give the patient a break. And give the Albuterol a break.

The problem with this is there is little science to back me up here. Yet, at the same time, there's little evidence to back the theory that continuous treatments do any good either, and we do them all the time at a pretty hefty cost.

Yet here I am on the defense again, even though the fans of giving continuous treatments are physicians and nurses who have no science on their side either.

So my plea here is for some research about continuous breathing treatments, and a plea to learn how long Albuterol sticks to those infamous B2 receptor cells in the lungs. Likewise, a plea for some common sense in the emergency room, and an end to fake theories about B2 medicine.


breathinstephen said...

Continuous nebs are the treatment of choice in the ER for severe asthma exacerbations here in California.

For me it usually starts in the ER with 3 back to back nebs f/b a continuous neb at 10-20mg albuterol/hour. On average I'm on an Albuterol nebs for 24-36 hours CONTINUOUSLY !

Anything over 4-8 hours seems like overkill to me. All it does is make my heart pound and make my potassium bottom out.

Of course it's easier for the RT to stick a person on continuous nebs,rather than to give Q1 treatments ATC.

I believe the beta receptor sites become saturated after about 4 hours.

Rick Frea said...

Our Medical Director told me when he orders continuous he's referring to three back-to-back-to-back treatments. That's the general rule of thumb for most docs where I work. You do that and reassess every 15-30 minutes. However, we have 2 docs who do order q1 hour treatments.

I couldn't imagine running a neb more than an hour. You would think that it would get the credit for opening up the patient's lungs when it's actually something else, like the steroids finally taking effect.

Yet, then again, as soon as the steroids cause beta receptor sites to open up, the beta adrenergics are right there waiting to fill the spot.

So I really can't argue against them. It would be neat to see some real science here. Perhaps there is some research I'm not privy to.

However, usually in the medical field we do science in reverse. Someone comes up with an idea, and we do it on everyone. Then we do it until it's proven not to do any good. Kind of like we did IPPB until it was finally decided all it did was overinflate good alveoli. We did that goofy thing for over 30 years until it was proven to be not necessary to improving outcomes. (although we do have one doc who still orders it from time to time).

So I imagine doctors and RTs and nurses will continue to recommend continuous nebs on certain patients until -- perhaps in another 30 years -- more evidence comes along.

Or unless the patient refuses I suppose.

Brenda said...

What are the side affects for giving 8 treatments to a 12 year old child?