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Sunday, May 25, 2008

Pneumonia is NOT an indication for Albuterol

Click here for the real indications for bronchodilator therapy.

One of my favorite things to do is educate. I always thought it would be cool if either all doctors went to RT school before they went to DR school, because that would teach doctors some good assessment skills, and how to know when a breathing treatment is indicated.

Either that, or perhaps it would be good to have an RT teach at DR school the indications of bronchodilator therapy and stuff like that. That in mind, this I am starting a new subject I will return to from time to time here at the RT cave: DR wisdom. And that is what this post is: Dr. Wisdom.

This will include information that I think doctors could use to become better doctors, or little things doctors can do to improve the DR-RT relationship. Heck, this will not only benefit the patient, it will make RTs happier, and make it so you doctors don't have to be bothered all the time.

First, let us consider RT Cave Rule #13

RT Cave Rule #13: In order to know that a breathing treatment is needed, you have to actually assess the patient.

So, that in mind, here is RT Cave Rule #12:

RT Cave Rule #12: Just because a patient has pneumonia is NOT an indication for a breathing treatment.

You came into the hospital, you assessed the patient and you saw the same thing that I saw when I assessed the patient, that he is in no respiratory distress and he even denies SOB. So why do you insist on ordering breathing treatments. Why?

Here is what you need to know. Ventolin is a particle size of 5 microns. That's a perfect size to work down into the bronchioles, bind with the beta 2 cells receptor cells, and relax the muscles of the bronchioles.

Now, note that pneumonia is not in the bronchioles, and therefore Ventolin will do nothing for pneumonia. Ventolin will not magically shrink to 1-2 microns and get into the alveoli and scrub the alveoli clean of pneumonia. That will not happen.

And even if the ventolin could somehow get into the alveoli, it would basically bounce off the alveoli and be absorbed by the body, because B2 receptor cells that it attaches to are not in the alveoli, they are in the bronchioles.

Thus, bronchodilators do nothing for pneumonia. In fact, I can tell you if that I never did one treatment on that guy you just ordered treatments on in CCU33, he would still eventually go home.

Please don't waste my time and make me wake up that poor guy every four hours round the clock for some stupid quacky uneducated theory you have.

Better yet, here is DR wisdom #11, of which I will be referring often in this class. So you better know this rule upside down and backwards:

RT Cave Rule #11: NOT everything pulmonary should be treated as bronchospasm. Ventolin does not work like Scrubbing Bubbles bathroom cleaner and scrub the lungs clean of all that ails them. It is for bronchospasm only.

We'll touch up more on this rule in our next session of DR wisdom.

That concludes today's class.

Note: I am aware that most doctors do not order bronchodilators for stupid reasons. And most who do are simply not aware of the real value of bronchodilators. That's exactly why we will hold these classes from time to time. Remember, we here at the RT Cave are leading the charge for bronchodilator reform. Thank you.


Djanvk said...

Excellent Lesson, how if some doc's read that posting, things might start looking up.

Freadom said...

Just wait, I have more. I tell you , I keep thinking I will run out of things to write about here, and then some doctor orders something stupid and it just sets me off.

You can't make this stuff up. It's like they just hand me material on a silver platter.

Glenna said...

I get bent out of shape over the constant unneccessary alb tx's too but I finally figured out one day that the RNs and Drs seem to know that it won't necessarily help but they figure it "won't hurt" and that it will make it look to the pt like we're doing something since a lot of pt's don't get what meds are hanging from their poles or being taken orally, i.e. antibiotics.

So my tactic now when I'm called by either to give a tx on a (any, really) pneumonia pt because they're feeling "pain in their chest" or "a little sob" or "anxious because their chest doesn't feel right" so a breathing tx will help them feel to say "so you want me to do absolutely nothing to help fix the problem but as a side effect raise their heart rate and make them even more jittery and weird feeling? That will make them feel better, go to sleep, and make your life easier?"

It's working. Most of the time the Rn looks at me and says "Oh. Well no. I guess not."

Guess not.

Anonymous said...

I am a pediatric nurse practitioner who sent a 2 yo child with pneumonia via transport to the ER from my clinic yesterday b/c he was hypoxic at 85% (it came up after 02). Though the ED report noted increased infiltrate from the last xray, crackles and tachypnea, they placed the child on Albuterol nebs, observed for a few hrs, and released him with orders for neb treatments every 4hrs. I was confused and frustrated and was happy to find some validation on this site that this is bad medicine. Let's hope the kid doesn't go into respiratory distress tonight.

beyr85 said...

thanks for the post!- Im a 4th year PharmD student, and this question was posed to me by the Fam Med team i'm rounding with, and I've spent the last hour trying to find any information on pubmed related to beta2 agonists and pneumonia, its funny (not to you guys im guessing) but the RT in the Peds unit told them that exact same thing you posted (not as descriptive) and they basically ignored her. Can't wait to give them the right answer and back up the RT

chris said...

Great web site love all the info.
I have been a RT. for 10 years the hospital that I work at now has a pneumonia pathway order sheet that they admit all pneumonia pt. on q4 tx. I just can't seem to get it through the docs. heads that these tx. are not always needed. just yesterday I ask a doc about pneumonia pt. not needing neb. so he wanted to just do nacl. tx. to break up the pneumonia, mindblowing. great site keep it up.

Rick Frea said...

I get that all the time. I don't know what doctors think Ventolin is. Perhaps Ventilin acts like a jumping bean and does internal CPT to knock thick and annoying secretions from the walls of the Bronchioles and Alveoli.

Rick Frea said...

Actually, Chris, you've inspired 2 new ventolin types. Click here and scroll down to 157 and 158. If you have any you'd like to add let me know.

Harry Buckles said...

Great post, but can you give any clinical trials? I'm a third year med student, and physiologically I fully agree with you. I'm trying to write a short paper on this for my peds class, but need to reference some studies.

Rick Frea said...

I have some information or you Harry. I actually wrote a post with you in mind. First I have to find it.

Rick Frea said...

Here are a bunch of articles I've written on the topic. I put an (x) next to the articles I thought would be most useful.

The funny thing is, if you look at the package insert, a bronchodilator is just that, a bronchodilator. It is indicated for COPD and asthma -- both diseases of bronchospasm.

Yet, in the hospital setting, it is often prescribed for any illness or condition that causes shortness of breath. And, while there have been many studies done to prove Ventolin benefits asthmatics and COPD patients when their smooth muscles are spasming (it causes bronchodilation), there has NEVER BEEN any study to prove that Albuterol helps any other pulmonary condition. Yet it is ordered any time a patient is short of breath.

First, As far as pneumonia is concerned, there has never been a study proving the use of bronchodilators will benefit the pneumonia. Think about it: Where is the pneumonia? It's in the Alveili. Ventolin particles are 0.5 microns. The alveoli is 0.1-3 microns. Albuterol can't even make it that far down into the lungs.

Second, there are no beta adrenergic receptors in the alveoli for the Ventolin to bind to. So, even if it did make it down that far, it won't do anything.

Third, pneumonia is a disease of inflammation. Albuterol is a bronchodilator, not an anti-inflammatory drug. If it were were an antiinflammatory medicine there would be no need for corticosteroids to treat asthma, and Albuterol would be the ideal asthma medicine.

But it's not. Albuterol does not cause a patient to hack up pneumonia. That's nothing but a fallacy. Yet you won't find any studies on it, because there's no need to. All you have to do is look at the facts: Albuterol is a bronchodilator and nothing more.

So basically, for your paper, is prove the documented use of Albuterol. It's used for that, and for a bunch of other reasons it does not benefit.

Why are bronchodilators ordered when they are not indicated.

1) Ignorance. Some doctors believe all shorness of breath is asthma
2) To make sure the RT is in the room every 4 hours to assess the patient
3) To make sure the patient meets criteria for admission so the hospital gets reimbursed. If the patient is bad enough to need breathing treatments, he's probably sick enough to need to be admitted.

Granted there are reasons to give Albuterol to pneumonia patients. If, for instance, there is some bronchospasm to go along with the pneumonia, then Albuterol is justified. In fact, I would give an initial treatment to any pneumonia patient who is having trouble breathing. If it improves airway function, then you can justify further treatments. If not, the therapy should be discontinued.

Good luck on your project. Email me if you have further questions

Rick Frea said...

Plus I would love to read your article when you're finished, and even publish it.

Anonymous said...


Rick Frea said...

So long as there is no asthma involved there's no evidence ventolin will help pneumonia. Some studies show Ventolin increases sputum production, and for this reason I think some doctors believe it will help the patient cough up sputum. Yet no sputum is produced in lung parynchema where the pneumonia is. So it's impossible that Ventolin will help the pateitn cough up pneumonia. It's simply a fallacy. I give treatments on pneumonia patients all day long, and about 90% say they notice no difference with the treatments. However, please note the purpose of my blog is to get people to thinking. I don't want something I said -- however factual -- to get you in trouble with your child's doctor. Good luck.

Amy said...

Glad I found this post. My son is 4 years and currently in the hospital for double pneumonia and tested positive for RSV. Before this time every cold he got went to his lungs and caused pneumonia. This didnt start until he was about 2 years old and around the same time the allergist/pulminologist 'thought' he had asthma. They told me to give him albuterol and pulmicort. which I did. I stopped both in Sept (mommys gut said they werent doing much except make his heart race).He has not gotten sick from Sept until now (Feb) the healthiest ever since being put on those meds. Glad I stopped them. Obviously it wasnt asthma! Can pulmicort or albuterol actually increase the chance for a cold to go into the lungs or depress the immune system if taken twice a day (for no real reason)? or increase mucus production from a cold to make ot easier to go to the lungs? appreciate any answers!

Amy said...

forgot to add that last night in the hospital my sons fever had gone down. Shortly after the RT came in to do a treatment (every 4 hours) his fever went up. when the RT came back I actually asked if the med could cause a fever or do something like raise the heart rate to precipitate a fever and he said No. agree?

lonesome devil said...

In dire need of some suggestions. I have someone I am close to in the hospital right now with what has been diagnosed as chronic eosinophilic pneumonia. This 40 year old woman, with immune deficiencies and considerable allergies, contracted pneumonia after a radical hysterectomy and was administered albuterol 6 - 8 times per day as a breathing treatment. They were instructed to test everything put into this woman but did not test the albuterol and after almost two weeks another Dr. came in and upped the dosage and she broke out with a rash. Obviously allergic.

She has been in the hospital for almost 5 months and has endured one thoracotomy and 3 thoracoscopies scraping her lungs and high doses of filgrastim to raise white blood cell count. After the third one, I dug into the research and brought questions to the Dr. such as "why not treat the cytokine activation and the fluid to the alveoli with glucocorticoids?"

They then stared a treatment of prednisone and she started improving. Going from 3 drainages per day to not being drained for 4 days until they decided to jack up the dosage of filgrastim for her white blood cell count. She started regressing again and they finally pulled her off filgrastim.

They upped the prednisone and she is back to 3 drains per day and fluid is building.

The albuterol is clearly at work here as she is continuing a reaction causing the fluid. Can anyone offer some information to help this poor woman who has been in IC for over 4 months???

We need some therapy that will address the effects fo the albuterol without stripping her immune system too severely.

Then Dr. has suggested dexamethasone and kenalog.

Thanks you for your consideration.

Anonymous said... about the case on bronchopneumonia? pneumonia also affects the bronchioles causing it to constrict dur to inflammation

Anonymous said...

Stop trying to make people think your smarter then a dr. Id rather have someone with 12 or more yrs of education making my medical decisions then someone with 2! Do your job RT! !...Ed Er

Anonymous said...

How's the kid supposed to breath while getting better? Crackles!!!? So just send him home with antibiotics n steroids only!? Nothing to HELP him breath!!? Good thing your not an Er doctor! Stay in the clinics!..please

Anonymous said...

No it opens the upper airways so that coughing up mucous and getting it out is easier!

Rick Frea said...

If it causes bronchospasm the treatment will work, but that's rare with pneumonia. Most of the treatments given have no effect. Bronchodilators will not help with shortness of breath unless it's caused by bronchospasm. If physicians did all the treatments they ordered they'd observe this the same way we RTs do.

Joseph Donohue said...

Albuteral is a Beta agonist. There's Beta receptors in the upper airways?? You should go back to your pulmonary anatomy books. Upper airways are vagally in-nervated. There are NO upper airways Beta receptors for albuterol to bond with.

Joseph Donohue said...

Wrong Ed! Do the same in your field of expertise also. This is one reason why healthcare costs are so high. The doctors commonly mis-prescribe this drug. 2-yr educated (same as an RN btw) RRT's are correctly reducing pneumonia rates with the appropriate therapy which includes d/c'ing unnecessary breathing treatments. Albuterol only relieves BRONCHOSPASM. It does not remove phlegm.

Anonymous said...

Doesn't take any training at all to qualify as an AH, Ed.

Anonymous said...

Actually, I am having a pneumonia right now - and if only take antibiotics, I dont cough much and if I do, there is no mucus. But if I take ventolin, I start coughing a lot and sure enough, all the mucus starts coming a patient who hates taking medicine in general...I must say, that ventolin does open something and does allow my lungs to get cleaner or emptier faster. Or at least it feels that way.

Rick Frea said...

Then you have asthma with your pneumonia. Albuterol will have no effect on pure pneumonia.

Anonymous said...

Hey guys, I could use your advice... I struggle with asthma and currently have pneumonia. I was given albuterol and have always been suspicious of that med. (also choosing not to take antibiotics. I'm a healthy 32 yr old and feel i can beat this without it.) I understand what i'm reading from you guys about albuterol particles not being small enough to get to the alveoli where the asthma is. However, I am short of breath from an asthmatic response to being ill. Any chance that, in my case, the albuterol may open my lungs, improve breathing, and allow oxygen to better reach the alveoli even though the albuterol can't? Trying to decide whether or not to use this albuterol neb. Thanks for any responses...

Rick Frea said...

I would recommend talking with your doctor and doing whatever he says.

Anonymous said...

Thank you for posting this. I wish more people were aware of this I just finished saying the same thing but your explanation is much clearer.

Anonymous said...

I am an RT. I understand the science of what you're saying but I've had pneumonia acouple times...both times I could breath better, easier and my cough was more productive. For whatever reason it helps me significantly. Not to argue but I disagree and think it helps people in many cases

john bottrell said...

That is because you also have a bronchospasm component with your pneumonia.