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Wednesday, May 7, 2014

Can RTs give inhaled volatile anaesthetics?

About five years ago, one of our fellow bloggers here on the RT Cave wrote a post about the benefits of using anaesthetics to treat refractory bronchospasm, or status asthmaticus.  So it's nothing new that anaesthetics provide some mild bronchodilating properties.

Back then, Rick Frea wrote the following:
Anesthetics: These are used to relax airway smooth muscles. According to Fatal Asthma, "Rapid, dramatic improvement is reported, leading to more effective ventilation and in some cases early extubation."
Ketamine is a smooth muscle relaxant and antihistamine, and is given intravenously. Of course this medicine is a known hallucinogenic, and it is a sedative. Many doctors prefer to wait until a patient is intubated to use it, and follow it up with a paralytic, as you can read here.
Isoflurane is an anaesthetic and bronchodilator that has been proven to be efficacious in ventilated patients in status asthmaticus. According to this study, " Isoflurane improves arterial pH and reduces partial pressure of arterial carbon dioxide in mechanically ventilated children with life-threatening status asthmaticus who are not responsive to conventional management."
In discussing this wisdom with a hardluck asthmatic friend of mine, he said, after reviewing his own chart, that he was on a ketamine drip while he was on a ventilator.  He asked his doctor why, and he explained that some anaesthetics had bronchodilator properties, and they were sometimes used as alternative therapies to treat status asthmaticus.

I have not heard anything further on this topic until a March 21, 2014, column by Tabatha Dragonberry at called "Inhaled Volatile Anaesthetics." She said she gave a lecture on the topic that focused on "inhaled" anaesthetics.

She said some states allow respiratory therapists to give the medicine by inhalations, although others do not.  Of course, in order to given volatile drugs in the emergency room, or in the critical care, RT departments would have to purchase anaesthesia ventilators, and RTs would have to become trained in how to use them (which shouldn't be too hard considering we already run ventilators).

Another change that would need to be made is to make sure it's legal for an RT to handle such medicine, and to give it to patients in need.  Plus there would have to be the support of the medical community.

Another article I found says that this type of therapy has been used at some hospitals for the past 20 years.

The article notes that considering the medicine can have some real serious side effects, such as hypertension and cardiac dysrhythmias, therapists would have to really pay attention to dosing, and to the patient, during and immediately after such therapy.

This might be a significant change for the RT profession, considering most of the medicines we give today have such negligible side effects that we often disregard them.  That would not be possible if we were allowed, on a routine basis, to administer volatile anaesthetics.

While there have been some studies that proved its effectiveness, others have shown the opposite: that all it does is increase cost and length of hospital admissions.

So, as with any medical procedure, I can see how it might be overused and abused by the medical community.  However, for those few patients that it truly benefits, it might be worth the added expense.

Overall, I think it would be neat to add this to our list of therapies given.  It would provide another option for physicians trying to care for their patients with refractory bronchospasm, it would also offer a nice challenge for the RT profession, a task that might help drive our profession into the next era of respiratory therapy.

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