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Sunday, March 1, 2009

Here are 12 diseases Albuterol does not benefit

As many of my readers know from reading my past entries Albuterol (and Xoponex> an too) is perhaps one of the most abused medicines in the hospital. While it is a bronchodilator designed to help asthma and COPD patients catch their breath, it is often ordered for diseases that have nothing to do with bronchospasm.

The truth is, Albuterol is a bronchodilator and nothing more.

It's so bad that my Rt coworkers and I often joke that doctors believe in the theory that, "All the wheezes should be treated as bronchospasm (or asthma)," or, "If he's short-of-breath he should get a bronchodilator breathing treatment," or, "If it's a disease in the lungs, a bronchodilator is indicated."

The truth is, all that wheezes is not bronchospasm, and all illnesses that cause shortness-of-breath are not indications for a bronchodilator, and all illnesses of the lungs are not reasons to order Albuterol. Yet that often seems to be the case, as you can see by this post.

What follows are ten common ailments patients are diagnosed with that often cause a doctor to order braething traetments for when a breathing treatment is not indicated and will have no effect on the disease.

1. Pneumonia: Pneumonia is inflammation in the alveolar sacs. Ventolin is 0.5 microns, and the Alveoli are 0.1 to 0.2 microns -- Ventolin can't even deposit into the lungs. And, if by some osmosis process it did make it down that far, it won't do anything anyway because Ventolin does nothing for inflammation, and it will not remove fluid from the lungs. For more information, check out this link here.

2. Cardiac Asthma (CHF, pulmonary edema): I wrote a good article about cardiac asthma a while ago, and I will link to it here. Albuterol does does not heal the heart, and it will not reabsorb fluid from the lungs.

3. Respiratory Syncytial Virus (RSV): This is a virus that causes swelling of the airways and increased secretions in neonates. Studies have been done that prove a bronchodilator is of no use, unless there is an underlying bronchospasm. Likewise, studies show sometimes racemic epinepherine is beneficial to these patients. In most cases, though, studies show simple suctioning of the nares usually clears the lungs before a treatment is even given, making it so a treatment is no longer indicated. I wrote an article about this here and also here.

4. Pneumothorax: This is a restrictive disorder otherwise known as a collapsed lung. It may cause severe shortness of breath, but once a chest tube is in place the patient may breathe just fine. Regardless, because it takes place in the lungs, a bronchodilator is often ordered.

5. Pleural Effusion: Again, fluid buildup around the lungs is a restrictive disease that lessens the ability of the lungs to stretch. Since this process takes place outside the bronchioles, shortness of breath caused by it will not be benefited by a bronchodilator.

6. Lung Cancer: Lung cancer can cause a wheeze because the cancer can put pressure on some bronchioles causing them to become narrowed (squeezing them), and thus they whistle. Since the narrowing of the bronchioles is isolated to one area of the lungs, and the cause is outside the bronchioles (a restrictive ailment), a bronchodilator will be of no use.

7. Fever: I think the theory behind doctors ordering treatments for fever is that they think it's caused by atelectiasis, and that the bronchodilator will somehow reinflate the alveoli. As we now know, Ventolin is too large in size (0.5 microns) to get into the alveoli. And, even if it somehow could get down there, it has no chemical properties that allow it to blow up flat alveoli like a tire pump blows up a flat tire.

8. Atelectasis: See Fever above. Some doctors see atelectasis, or hear it upon auscultation, and assume a breathing treatment will be of some use. Ventolin will not reinflate deflated alveoli.

9. Post operative (prophylactic): One of the surgeons at Shoreline Medical once told me he ordered postoperative breathing treatments because they keep the lungs "clean and open." For this reason one of my co-workers jokes that doctors think Ventolin works the same as Scrubbing Bubbles in that it suds up in the lungs and washes away any crud that might be in the lungs. The truth is, if there is no bronchospasm, a bronchodilator is of no use to the post operative patient.

10. Airway congestion, colds, or influenza: Stuffiness caused by congestion caused by head and chest colds will in no way go away with Ventolin. It will also not clear a stuffy nose. However, it is often ordered for this reason. However, if these ailments may compound asthma and COPD.

11. Meet criteria: This is not necessarily a disease, but it might as well be. Many treatments given in hospitals are not ordered because they are indicated, but because they are needed to meet criteria for reimbursement. Recently I wrote about this over at RT 101. I also wrote a recent post (click here) guestimating how much money is wasted doing non-indicated breathing treatments

12. Pulmonary Embolism: I just about overlooked PE, so here I must add it to the list. A PE is a blood clot that formed in the legs or elsewhere in the body, dislodged, and finds it's way to the pulmonary artery in the lungs and bocomes lodged there. Many times a patients may have two or three PEs at one time. It usually causes symptoms such as crackles, shortness of breath, cough, rapid heart rate, wheezing, leg swelling, anxiety and fever. A PE can usually be discovered via testing, and once the symptoms are figured to be a PE no further breathing treatments should be given. This disease is a good examle of: All that is short of breath is not bronchospasm.


Glenna said...

I think another reason we're called for Alb tx's on fevers is because it's automatically assumed that if a pt has a fever they're getting pneumonia...which cycles us back to the assumption that albuterol is going to help pneumonia.

Boy, those really are our bane, aren't they? I spend more time educating about what NOT to use albuterol for than any other thing when I work the floor.

I'd like to add to the list: pulmonary embolism. Again, restrictive and a perfusion problem but the clots can press, you hear a wheeze, and it's assumed that albuterol will fix the wheeze and "help open the lungs". Nope, busting up the clots will help the pt.

Freadom said...

Foolish me. How could I miss PE? I will add it to the list.

Fran Groves said...

Back in the dinosaurage, we did IPPB TID with N/S. On all post-op patients! It's gonna take time to get Doctors to do it right. Once the are getting thier hands slapped for ordering albuterol they will stop.