Combination Inhaler Abuse In Hospital Setting

Combination inhalers (like Symbicort) are now standard for asthma and COPD. They are included in nearly all asthma and COPD guidelines. The goal is that, by using them once or twice a day, this should make it so you rarely experience symptoms. And, with few symptoms, rescue inhalers should be infrequently used. 

In the hospital setting, doctors tend to order combination inhalers even when the patient is already getting nebulizers. For instance, a patient may be getting Duonet QID and Symbicort BID. And this is the case for COPD and asthma, but also the case for any other patients requiring breathing treatments. 

It makes me wonder ifAlright, folks, let’s break this down. Combination inhalers like Symbicort—those trusty tools in the battle against asthma and COPD—are the gold standard. They’re in all the guidelines. Use them once or twice a day, and you’re supposed to keep symptoms at bay, leaving that rescue inhaler collecting dust in the drawer. That’s the idea, anyway.

But here’s where things start to get interesting in the hospital setting. Doctors are piling on these combination inhalers even when patients are already getting nebulized treatments. A patient might be on Duoneb four times a day and Symbicort twice a day. And it’s not just for asthma or COPD; they’re ordering this for anyone requiring breathing treatments, regardless of the underlying condition.

Now, I have to wonder: are these doctors unaware that this is duplicate therapy? Or maybe—just maybe—they’ve got access to some next-level knowledge the rest of us mere mortals don’t.

Look, I’ve got no problem with Symbicort. It’s a fantastic inhaler. But does it need to be prescribed for every single patient needing breathing treatments? Let’s use a little common sense here. When a patient gets admitted, sure, start them on Duoneb. But once they’re breathing easy, shouldn’t we be stopping those nebulized treatments and transitioning to Symbicort—if they have a diagnosis of asthma or COPD? Makes sense, right?

At my hospital, we RTs follow protocol and discontinue treatments when patients are stable, only to have the doctors swoop back in and reorder them. Sometimes they even get irritated, as if we’re trying to dodge work. But the truth is, we’re not cutting corners; we’re doing what’s best for the patient. If they’re breathing fine and already on Symbicort, they don’t need the Duoneb anymore.

It’s redundant, inefficient, and, quite frankly, unnecessary. Yet, this seems to be the reality we’re dealing with. Are the doctors unaware that this amounts to duplicate therapy? Or perhaps they have some esoteric knowledge or evidence guiding their decisions that the rest of us haven’t seen.

I'm fine with ordering Symbicort. It is a great inhaler. But does it really need to be ordered on every patient admitted to the hospital requiring breathing treatments? Ideally, I think, when a patient is admitted, they should beg ordered on Duoneb. And, once they are breathimng easy, this therapy should be stopped and Symbicort add3ed -- if the patient has a diagnosis of asthma or CoPD. 

But, where I work, per protocol, we RTs DC treatments for this reason, only to have the doctors reorder them. They may even get upset sometimes that we are getting rid of their orders, perhaps thinking we are being lazy and trying to get out of work. Yet, the reality is, we are getting rid of them because the patient is breathing easy, is getting Symbicort, and no longer requires the Duoneb set at a frequency. Silly. Duplicitive. But that's what we deal with. 

I'm not sure why this is. I have worked very hard at educating doctors a few years ago. And my campaign was very successful. Yet, a few weeks after it was decided not to order duplicate treatments anymore, the doctors went right back to ordering duplicate orders again. Meaning, it's very common to see a patient oin Duoneb QID and Symbicort BIDs.