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Tuesday, September 23, 2014

Albuterol no longer just for bronchospasm

The best article ever published in a peer reviewed respiratory therapy journal was by a former coworker of mine by the name of Forest Dipzinski titled "Albuterol: not just for bronchospasm anymore."

The article was originally published in Advance Magazine August 12, 1996. Anyway, here it is in its entirety.  Enjoy!

I don't know why drug companies are spending millions of dollars on research and development for new drugs. If they would just empty their medicine chests, they could take some old standard drugs, get new labels, hire a public relations firm and be in business just targeting an existing drug for new use.

At least that's what seems to be the case with Albuterol. That drug is probobly the wonder drug of the late 20th century, and most people, including the drug manufacturers, don't even realize it.

In the current age of downsizing, I guess I should just be glad some caregivers don't know CHF from bronchospasm. Because in an age where traditional roles are becoming extinct, at least I know I'll have a position somewhere and my family will be clothed and fed. Yet, I become frustrated at times due to the waste I see in the medical profession.

In some instances, the waste comes from the inordinate amount of unnecessary therapy we do. I can still remember taking my oral pharmocology exam at school and the instructor asking "Why do we give Alupent?" "Oh, for pneumonia, cancer, coughing, sputum induction, atelectasis, emphysema, bronchitis, just to name a few." I replied."No," he said, "I mean, what's the indication for giving it?" "You didn't ask me that," I answered tongue-in-cheek."The indication is bronchospasm, but it seems I give it for everything but that".

That was 12 years ago. Little has changed since then, even though bronchodilators have improved and are much safer. One of the most widely used is Albuterol. It's fast acting, has few side effects, is long lasting and "melts in you mouth, not in your hand". As therapists, you know, it's a great drug.

Why do we give it? The following are some of the reasons I have found. But first a warning! The following statements are taken verbatim. Only the names have been changed to protect the inocent. The following reasons were taken from patient charts.

1- "Will continue nebs and CPT to treat pleural effusions."
2- "Med ordered: Albuterol. Dosage: Unit Dose. Indication: Pleural effusions."
3- "Patient has hypertension. Will treat with nebs."

Here are several tales straight from the bedside:

1- A middle aged woman with cancer was on a ventilator. Thin red secretions were pouring from her tube. There was some debate on wether this was blood or pulmonary edema. One resident piped in with the helpful suggestion:"Maybe she needs a neb." The glare of the therapist accompanied by the therapists reply "You've got to be joking!"got a retraction.

2- Another patient with cancer was on the vent post-op. After making several appropriate recomendations for nutritional support, the nurse turned to the attending physician and said: "Well, he's not getting nebs and chest PT, you know, the things you normally do to wean a patient."

3- Here's an excerpt from a conversation between an RN and an RRT in reference to a patient who is two days post-op following a coronary bypass operation. The patients breathe sounds are clear except for diminished bases. "I paged you because he needs his neb and chest PT. His CO2 is 58," explained the nurse to the therapist. "You mean the patient needs to cough and deep breathe because he's hypoventilating," replied the therapist. "No, he needs his treatments because his CO2 is up," she hissed and walked away.

So far, from the data documented to this point, we've established that Albuterol can be used as an aid in pleural fluid removal, a coagulant, a surface tension reducer, a weaning adjunct, and an arterial CO2 reducer in patients who are hypoventilating due to incisional pain. But there's more...

Have you ever noticed that whenever a patient has any type of surgery, he gets Albuterol. One patient had eye surgery, had clear breathe sounds, was sucking 2000 ccs on his incentive spirometer and was still ordered to receive Albuterol nebs followed by CPT q 6 hours. On the same floor, another post-op patient who was using his incentive spirometer q 1 hour and achieving 4000 ccs was ordered to receive the same therapy only q 4 hours.

So, Albuterol enhances surgical would healing. Amazing!
But there's still more...

A few years ago, a post-CABG patient who was receiving Albuterol nebs q 4 hours, was about to be transferred to the step-down unit. I asked the surgeon if he felt she still needed the nebs. "Yes, she'll get lonely without them," he said. Well, that topped it all. Albuterol can also be used as an anti-psychotropic. What a drug! And they say Bayer is the wonder drug that works wonders!

Of course, there are other uses for the drug too. It increases PO2, enhances healing of long bone fractures, and makes a great food additive. I've been told on good authority, however, it's use in male pattern baldness is only experimental at this time.

In defense of the ordering physician, it is only fair to point out that in this age where you can be sued for looking cross-eyed at someone, physicians can hardly be faulted for covering all their bases. Albuterol won't hurt, and may possibly help. So why not order it?
Times are changing. That's why.

Many institutions are converting to Budget Focused Care (a.k.a. Patient Focused Care). This has to be deemed necessary due to the rising cost of health care. Something has to be done to hold down the high cost of health care. I agree with that concept! And while a little education isn't the entire answer, maybe it wouldn't hurt either.

Here's how education could help. If we educated caregivers to do only necessary procedures and if health care providers were allowed to practice what they've been trained to do, then costs would be lowered. By curtailing meaningless procedures, an institution could cut conciderable manpower.

In the wake of such a change, those who did provide only needed care could then be truely patient-focused. It's a little difficult to be as patient-focused as possible when you're giving Albuterol for everything from hangnails to sprained ankles.

Such a move to what therapists like to term Therapist-Driven protocols would require caregivers to justify every procedure. Such a change would certainly get rid of the old "shot-gun" approach to patient care where everything and anything that can be done should be done.

Gone too in the process would be the attitude of one surgical resident, who, when asked why we were doing nebs and CPT on a patient with clear breathe sounds, said, "because I want them done!"
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1 comment:

migraneur said...

These statements make me so glad I've always worked with a protocol. I've listened to the pt, checked the chart for any lung dx, completed an evaluation, and dc'ed the order.

Now that won't stop the truly intent MD from exempting the pt, and reporting, but it stops about 95% of unneeded albuterol.

I'm also bold enough to tell the doc in the vented pt scenario that albuterol won't fix it, not even if I pour it down the ETT, let alone add a neb.