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Wednesday, January 30, 2013

Reality versus science: The Nebulizer debate

I think too much emphasis is put into how long a breathing treatment lasts.  I think too much emphasis is put into how much of the medicine is wasted. I think scientists stress over these things, but patients couldn't care less.

It's true that a treatment should last until the sputtering starts, as opposed to ten minutes.  It's true that 75 percent of the medicine is wasted, because the treatment is run continuously through the inspiratory and expiratory phases of respiration, which is a one to three ratio.

These truths seem to stress some people out.  My argument about this is: who cares? What difference does it make?

My argument is this.  When I'm having an asthma attack, I don't care about what science says.  The fact is, a breathing treatment is better than an inhaler during an asthma attack.  The reason is you don't generate good flow to inhale the medicine by inhaler.

You do not need to sit there and tap the nebulizer cup to make the treatment last ten minutes, when  most of the time all it takes is 1-2 minutes inhaling Albuterol to get your breath back.  I find this to be the case 90 percent of the time I use my nebulizer, and when I ask my asthma and COPD patients, most of them tend to agree.

The exception here is when the treatment doesn't give a person his breath back.  It's these people, those with COPD more than likely, where the cause of dyspnea is due to permanent damage to the air passages or cardiac failure, or a severe attack.  In the case of heart failure, the treatment will have nothing to do with the patient getting his breath back.  In this case it's simply rest; allowing the heart to catch up.

In the case where the treatment doesn't open the lungs all the way, having a nebulizer that has the ability to eliminate wasted medicine will not make the medicine work better.  If a patient needs more medicine, all he has to do is take another breathing treatment.  It's that simple.

There are some who want to make the treatment last longer by way of one way valves.  But I hate one way valves because all they do is make it hard to suck in the medicine.  I don't know about you, but when I'm short of breath I don't want to suck in harder.  So I pray they don't put one way valves on all nebulizers.

However, and this is where it gets tricky.  I do believe that in the hospital setting we are spreading germs through the mists we create.  Here we have patients come into the ER coughing and we place masks over these patient's airways to prevent them from spreading their germs, and then we take the mask off and give them a breathing treatment to spread those germs.

Here I think a one way valve would be nice, if it was proven to stop the spread of germs.  And considering 90 percent of the treatments we give are useless, I'm all for this.  The problem is, my boss doesn't understand why we can't just give all breathing treatments this way.  I try to explain to him that asthmatics and COPDers feel more dyspneic inhaling through the resistance created by the one way valve.

So the battle continues.


Unknown said...

A unit dose albuterol neb is 2.5 mg, while a puff on an inhaler is 90 mcg. That's a big difference in dose. One study showed that a unit dose of nebulized albuterol delivers the same amount of medicine to the lungs as 11puffs on an inhaler with spacer. So that's why it doesn't take the whole treatment to work.

If hospitals, drug companies, and physicians were so concerned with wasted medicine and maximized delivery in nebulized albuterol, they would have us use the $5 breath actuated nebulizers instead of the cheap 50 cent ones, and then lower the amount of medicine in a unit dose. But albuterol is an emergency/rescue medicine with little to speak of so far as side effects, so it is the way it is.

Rick Frea said...

And the people who really need the medicine can't generate enough flow to use the breath actuated nebs. Personally, the breath actuated nebs are uncomfortable to use.

Amber said...

As a patient the breath activated ones are a nightmare when you are in an active exacerbation. I personally prefer the mask as opposed to the handheld clench in teeth ones. The breath activated ones are alright and have even encouraged me to expand my lungs and breathe deeper when given when I'm not in active distress. If given breath activated during a crisis, I flip the valve to continuous on my own. I'm more interested in opening my airway as comfortably as possible for me rather than trying to extra tough it out and respiratory arresting. I've been there, done that a few times, I finally learned my lesson and get and seek treatment earlier now if all my efforts do not improve my exacerbation.