The best way to add value to aerosol therapy

So I'm reading this article in RT Magazine called "Adding Value to Aerosol Therapy" by Mark Grzeskowiak.  The article is about adding value to aerosol therapy without cutting on quality of care.

He writes:

When a respiratory care practitioner enters a hospital room, they bring with them their experiences, assessment skills, and the necessary equipment to the bedside in order to make a patient’s breathing a little easier. But in today’s healthcare environment, there is an increasing emphasis on becoming more productive. RCPs must be able to do more in less time and with fewer resources. This scenario can sometimes leave the RCP wondering which goal is more important: providing quality care, or completing more billable procedures.

In the case of aerosol therapy, value can be added to the treatment by increasing quality while decreasing costs. However, inexpensive products do not always provide a reasonable quality of care, and it is up to respiratory care departments to resist cost-cutting strategies that look good on paper but may compromise patient care. This article will focus on strategies that can allow RCPs to provide high-quality care and still keep budget offices happy.

He offers some viable solutions:

1. Adding value with equipment:  Here he explains that by preventing half the medicine from being wasted, the patient will get more of it. This can be done by adding a reservoir to the end of the nebulizer.  Another solution is breath actuated nebulizers.  The problem with these options is that the equipment costs more, with the breath actuated costly slightly less than the reservoir nebulizer.  Personally, I think it would be too hard for some patients with true bronchospasm to initiate the breath actuated nebulizer, and I think it would be less expensive just to give another breathing treatment when it is indicated. I emphasize "when indicated" because most patients would probably not need the second treatment anyway.  
2. Adding value by subtracting:  This would involve eliminating aerosol therapy for patients where there is no perceivable benefit.  The problem is that too many doctors and nurses thing aerosol therapy is the solution for all annoying lung sounds and all causes of dyspnea.  Personally, if a hospital would incorporate a system of RT driven aerosol therapy protocols, I think this is the way to go.  I think this would save the hospital money, save the insurance companies money, save the government money.  It would  even reduce RT burnout and apathy, and stop RTs from waking up patients in the middle of the night for no good reason.  It's a win-win for everyone. 
3. Adding value through change in practice:  Give a mouthpiece instead of a mask, because studies show 50% more medicine is lost when a mask is used. Placing the aerosol close to the patient in a ventilator or BiPAP circuit. The problem:  Most of the time masks are used by patient preference, or because the patient can't hold a mouthpiece.  Personally, if the patient needs more medicine to feel better, then we might as well be giving two breathing treatments.  If we went with option #2 above, giving an extra treatment once in a while when needed would not be a burden either financially or physically.   

I think another option that's missing here is to use metered dose inhaers (MDI) instead of aerosols.  Most studies show that aerosols are equally as effective at delivering medicine to the lungs as MDIs used properly with a spacer.  So, once a patient is breathing normal, MDIs should be used.

Albuterol MDIs cost about $40 a piece, and the instruction cost is about $140, which is way less than the cost of aerosol therapy, which is estimated at between $100 and $200 each treatment.

I think you can work to try to find better ways of delivering aerosolized medication to patients, but the best method of cutting costs, if that's the goal, is simply to make sure such therapy is only given to those who would truly benefit from them, and the only way to accomplish this is with RT driven protocols.

If, on the other hand, physicians are intent on giving aerosol therapy, then RTs should be allowed, per protocol, to give MDIs to those who can generate enough flow and otherwise coordinate the therapy.

Can RTs give inhaled volatile anaesthetics?

About five years ago, one of our fellow bloggers here on the RT Cave wrote a post about the benefits of using anaesthetics to treat refractory bronchospasm, or status asthmaticus.  So it's nothing new that anaesthetics provide some mild bronchodilating properties.

Back then, Rick Frea wrote the following:

Anesthetics: These are used to relax airway smooth muscles. According to Fatal Asthma, "Rapid, dramatic improvement is reported, leading to more effective ventilation and in some cases early extubation."

Ketamine is a smooth muscle relaxant and antihistamine, and is given intravenously. Of course this medicine is a known hallucinogenic, and it is a sedative. Many doctors prefer to wait until a patient is intubated to use it, and follow it up with a paralytic, as you can read here.

Isoflurane is an anaesthetic and bronchodilator that has been proven to be efficacious in ventilated patients in status asthmaticus. According to this study, " Isoflurane improves arterial pH and reduces partial pressure of arterial carbon dioxide in mechanically ventilated children with life-threatening status asthmaticus who are not responsive to conventional management."

In discussing this wisdom with a hardluck asthmatic friend of mine, he said, after reviewing his own chart, that he was on a ketamine drip while he was on a ventilator.  He asked his doctor why, and he explained that some anaesthetics had bronchodilator properties, and they were sometimes used as alternative therapies to treat status asthmaticus.

I have not heard anything further on this topic until a March 21, 2014, column by Tabatha Dragonberry at advanceweb.com called "Inhaled Volatile Anaesthetics." She said she gave a lecture on the topic that focused on "inhaled" anaesthetics.

She said some states allow respiratory therapists to give the medicine by inhalations, although others do not.  Of course, in order to given volatile drugs in the emergency room, or in the critical care, RT departments would have to purchase anaesthesia ventilators, and RTs would have to become trained in how to use them (which shouldn't be too hard considering we already run ventilators).

Another change that would need to be made is to make sure it's legal for an RT to handle such medicine, and to give it to patients in need.  Plus there would have to be the support of the medical community.

Another article I found says that this type of therapy has been used at some hospitals for the past 20 years.

The article notes that considering the medicine can have some real serious side effects, such as hypertension and cardiac dysrhythmias, therapists would have to really pay attention to dosing, and to the patient, during and immediately after such therapy.

This might be a significant change for the RT profession, considering most of the medicines we give today have such negligible side effects that we often disregard them.  That would not be possible if we were allowed, on a routine basis, to administer volatile anaesthetics.

While there have been some studies that proved its effectiveness, others have shown the opposite: that all it does is increase cost and length of hospital admissions.

So, as with any medical procedure, I can see how it might be overused and abused by the medical community.  However, for those few patients that it truly benefits, it might be worth the added expense.

Overall, I think it would be neat to add this to our list of therapies given.  It would provide another option for physicians trying to care for their patients with refractory bronchospasm, it would also offer a nice challenge for the RT profession, a task that might help drive our profession into the next era of respiratory therapy.

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The idea RT Aerosol Protocol

I'm not a fan of protocols that are based on an algorithm.  I also do not like utilizing points systems to determine frequency of therapy.  I think the best approach is simple common sense.

In a points system you assess the patient and review the chart to determine breath sounds, pulse, respiratory rate, and level of shortness of breath.  Then you give the patient a points based on what you find.  The total points score will be between 0 and 12.  This will help you determine the frequency of therapy.

• A total point value of 0-4 = PRN
• A total point value of 5-7 = QID
• A total point value of 8-10 = Q4/ PRN
• A total point value of 11-12 = Q2

I'm not a fan of these systems at all.  First off, wheezes are totally over rated.  You could have someone with a throat wheeze, or laryngospasm, or a cardiac wheeze, and that can completely be confused for bronchospasm wheeze.  Plus dyspnea can be caused by an assortment of disorders, bronchospasm being just one.  

I think a better approach would be to determine need for treatment by giving one treatment, assessing whether or not it did any good, and then ordering subsequent treatments based on that.  

I also think that no one should get a treatment unless they are short of breath.  If you go into a room to assess a patient and he is sleeping, or otherwise is breathing fine, then you should not give the treatment.  If the doctor wants to give prophylactic beta adrenergic medicine, then he can order long acting beta adrenergic therapy.  

Bronchodilator aerosol therapies should be ordered as prn for most patients, and QID for patients who are difficult to assess, or who cannot tell you how they feel.  The only aerosolized medicines that should be given on a frequency are medicines like Pulmocort and Brovana, which need to be given twice a day.  

Why give treatments to intubated patients?

Studies show that about 75 percent of the medicine given by aerosolized nebulization is wasted to the atmosphere.  When it comes to an intubated pateint, the studies show about 97.1 percent of the medicine is wasted.

According to MacIntyre, "Aerosolized delivery in intubated, mechanically ventilated patients," Critical Care Medicine, 1985 (13, 81), the amount of inhaled medicine that gets to the air passages of an intubated patient is even less, about 2.9 percent. This information is according to James Fink.

So according to this evidence, there really is no reason to give an aerosolized breathing treatment to an intubated patient.  If a physician wanted to give the equivelent dose to an intubated patient as compared to a nonintubated patient, he would have to give about eight treatments.

According to Gay, et al, "Metered Dose Inhalers for Bronchodilator Delivery in intubated, mechanically ventilated patients," Chest (1991, 99, pages 66-71), a metered dose inhaler treatment is equally effective as compared to a nebulzed breathing treatment.

A 1993 study reported in the American Review of Respiratory Disorders, "Metered Dose Inhaler Versus Nebulized Albuterol in Mechanically Ventilated Patients," concluded that for non-intubated patients a properly used MDI treatment is equally as effective to a nebulized treatment.  Yet when a patient is intubated, a nebulzier works better.  They conclude as I did above, that to get more of teh medicine, more breathing treatments should be given.

In the study, 7.5 mg of albuterol was given in a breathing treatment led to a reduction in resistance in 8 of 10 patients, and 100 puffs of albuterol MDI had no effect on resistance

A problem with studies like this is the method of delivering the MDI to the patient.  Later studies showed that by using appropriate spacers in the ventilator circuit, the MDI is of equal efficacy to an aerosolized breathing treatment.

Plus, as an added incentive not to use an inline nebulizer treatment, some of the aerosolized particles were impacting inside the ventilator, and this was causing problems with the machines.  This was the main reason Shoreline Medical does not allow physicians to give nebulizers treatments to intubated patients, and we use MDIs instead.

According to Claude Guerin, et all, "Inhaled Bronchodilator Administration During
Mechanical Ventilation: How to Optimize It, and For Which Clinical Benefit?, Journal of Aerosol Medicine and Pulmonary Drug Delivery, (Volume 21, Number 1, 2008), The amount of bronchodilator that deposits at its site of action depends on:

1. Amount of drug
2. Inhaled mass
3. Deposited mass

The challenges of Mechanical Ventilation on aerosolized deposition to the lungs are:

1. Ventilatory circuit
2. Endotracheal tube
3. Ventilator settings

Guerin, et al, concluded that the ETT is not as significant a barrier as once thought.  As I noted above, the key variables that effect deposition to the airway in intubated patients are:

1. Attachments of the inhalation device in the inspiratory line 10 to 30 cm to the endotracheal tube
2. Use of chamber with metered-dose inhaler
3. Dry air
4. High tidal volume
5. Low respiratory frequency
6. Low inspiratory flow (which can increase the drug deposition)

The evidence shows, according to Guerin, et al, that there is no difference between reduction in resistance from an MDI and Nebulizer in an intubated patient, and therefore either one can be used for this reason.  

However, many hospitals have chosen to use the MDI instead due to the following reasons:

1. Cost effect:  Each nebulized treatment exceeds $100, plus the cost of the medicine for each dose.  The inhaler is one charge for the medicine, which is probably around $20 (or probably less when you include the hospital discount)
2. Time Savings:  An inhaler treatment can be given in less time
3. MDI = less medicine deposition into the ventilator

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.

When do you end a breathing treatment?

A question of much debate in the respiratory therapy community is when to end a breathing treatment.  Many hospitals have a policy that the treatment should last up to ten minutes, while others contend it takes less than five.

Some respiratory therapists, and many patients, tap the nebulizer until they presume all the medicine in the cup is gone, while others simply end it once the medicine in the nebulizer cup starts to sputter.  So who is right and who is wrong?  Is tapping necessary?

According to the experts a breathing treatment ends when the medicine starts to sputter, and by this time most of the medicine is gone.  This was discussed by Dr. Bruce Rubin and James Fink, RRT, in their 2003 article, "The delivery of inhaled medication to the young child," in Pediatric Clinical of North America (50, pages 717-731).  They write:

Most of the available medication in the nebulizer cup is nebulized in the first
few minutes [10]. All nebulizer cups have some amount of medication remaining
near the end of therapy, when aerosol generation becomes intermittent. This
intermittent nebulization is referred to as sputtering; it has been documented that
aerosol delivery to the patient declines by half within 20 seconds of the onset of
sputtering [13]. At this time it is appropriate to discontinue therapy.

Accordingly, the the study showed that (2, page 316):

Albuterol delivery from the nebulizer stopped with the onset of inconsistent nebulization (sputtering).  Continuation past the past the point of jet nebulizer sputter is ineffective and should indicate an end of the treatment.  

So there you have it.  Now you know when is the best time to end a treatment.

Further reading:

• Most of aerosolized medicine is wasted

References:

1. Rubin, Bruce K, M.D., James B. Fink, RRT, "The delivery of inhaled medication to the young child," Pediatr Clin N Am 50 (2003) 717– 731.  Note:  James Fink is one of the foremost experts on aerosol delivery and has been involved in many tests and written many articles on the subject.  You should Google him to see what else he has written.  You might be impressed.
2. Hess, Dean, Neil MacIntyre, Shelley Mishoe, William Galvin, editors, "Respiratory Care Principles and practice," 2nd edition, 2012, Jones and Bartlett, page 316

Monday's class: My response to your queries

This post is my weekly attempt to answer Internet search engine queries that lead someone to clicking onto my medblog.

We determined last week that 62% of people who click onto this blog stay here long enough to determine it's not where they want to be. Likewise, we also determined that if they would have stuck around a bit, they may have found the answer they were looking for.

Of the 500 queries in my stat counter's memory, I have picked ten of the most interesting queries. Keep in mind I do not answer queries if the page the person landed on would have provided them with an appropriate answer.

Here we go:

1. Frequency of Duonebs: Duoneb is a combination of Atrovent and Albuterol, and ideally it should taken no more often than every four hours. If you need to use it more often you should see your doctor. This medicine can be safe if used more often, but should not be done without the approval of a doctor.
2. am i smart enough to be respiratory therapist: When I first researched the career of RT I found out I had to take chemistry, and I failed chemistry in high school. Based on this, I decided RT school would be too hard for me. I could not have been more wrong. If I'm smart enough to be an RT, you are too.
3. respiratory therapy is not a good career: That kind of depends on how you define a good career. If you want to get rich and buy a bunch of material items, then this is not the career for you. Like any job, there are ups and downs of being an RT. It is what you make of it.
4. xoponex q2: It's safe. However, I would not recommend this frequency outside the hospital setting.
5. albuterol pulmonary edema: Albuterol has absolutely no effect on Pulmonary Edema. Albuterol relaxes the bronchioles, and pulmonary edema occurson the outside of the bronchioles. For more information see #9 below.
6. do respiratory therapists use stethoscopes: Absolutely. If you see one who doesn't you ought to report him or her and wonder if you are receiving good care.
7. what happens to fio2 when using a simple mask and the patient breathes deep: The simple mask is a low flow oxygen device, meaning that the FiO2 is dependent on the patients respiratory rate and tidal volume (minute ventilation).
8. i hate my job, respiratory therapy: It's a free country. Nobody is stopping you from getting a different job. Go for it.
9. does wheezing mean you have copd: Not always. If the muscles of the bronchioles are spasming, this will cause a wheeze. This is called brnchospasm and occurs with COPD or asthma. Albuterol can relax these muscles almost instantly, making it much easier to breathe. Pulmonary edema occurs as a result of the heart pooping out, and fluid backs up and fills the lungs. This can be caused by Chronic Heart Failure (CHF). If the pressure in the lungs gets high enough with CHF, this fluid in the lungs will actually squeeze the bronchioles, causing a wheeze. Because this is caused because of a weekend heart, it is called a cardiac wheeze. Sometimes, however, it is hard to tell the difference.
10. Bipap asthma: I've actually seen it work well for some asthmatics, however when an asthmatic is really short of breath he may actually feel claustrophobic enough without the BiPAP. Thus, if the patient can tolerate it, go for it. BiPaP should always be ordered to tolerance.
11. continuous aerosol with atrovent: I questioned it too, but some doctors where I work have done it with no consequences. Atrovent is similar to Albuterol in that the side effects are minimal. If Albuterol is safe, Atrovent is even safer. Some recent studies show some added benefits to COPD and Asthma patient with giving continuous Atrovent along with continuous Albuterol. As with everything in the medical field, every doctor or RT will have a different opinion on this. With that in mind, I do not see any point in giving a continuous treatment with just Atrovent. If a patient is so short of breath he or she needs a continuous treatment, then you better throw in some Albuterol. (Note: a continuous treatment is when you give a treatment back to back to back until the patient starts to open up.)

Keep in mind I receive hundreds of queries a week, and I am limited in space on this weekly column.

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact us at Freadom1776@yahoo.com, or RTcave@yahoo.com.

That concludes today's class.

From asthma cigarettes to a normal life

Millions of people are alive today becuase of modern medicine, as would probably be true of a majority of the patients we as RTs take care of on a daily basis.

When I was a kid, as I puffed on my Ventolin inhaler for the umpteenth time, or visited the hospital and was given instant relief after a shot of Susprin (Epi), I often wondered if I had lived a hundred years earlier if I would have lived to be a year old. Chances are I would not have.

I remember my grandma telling me the story of her peering through a slightly ajar door into a small room at the old Mercy Hospital as doctors picked up her little brother and frantically held him upside down, patting him on the back, trying to clear the junk from his lungs.

Her little brother didn't live to his second birthday.

He had bad genes, as I have bad genes, as probably do most of our respiratory patients. And, perhaps, had he survived that illness, he would have grown up to have asthma, and probably would have lived miserably as the treatment for that disease was primitive.

When I worked for the museum in Port City they had a shelf with a bunch of 100 year old medicine from an old pharmacy, and one of the medicines was an old box of "Asthma Cigarettes." During an exacerbation of asthma patients were encouraged to smoke.

The medicine had a drug called Stramonium, which, according to this article by the American Journal of Respiratory and Critical Care Medicine is a "dried leaf and the flowering or fruiting tops of the plant, Datura stramonium. This is also referred to as the thorn-apple plant. The active ingredients in this were alkaloids of belladonna, which we now know had the effect of inhibiting cholinergic neurotransmission and thereby reflex bronchoconstriction."

Preventative medicine, also according to this article, was used in the treatment of asthma back then just as it is today. And still, however far we have revolutionized the treatment of asthma, "It is still somewhat controversial as to whether allergen elimination leads to an improvement in asthmatic status. There have been recent controlled clinical trials in which selective covering of mattresses with house–dust-mite–proof covers failed to show a benefit in asthma severity or lung function."

The Belladonna plant was used in the ancient world as far back as Ancient Greece, but more as a sleep aid or as a opiate for poisons rather than as a bronchodilator.

A derivative of the Belladona plant called Atropine was used in the treatment of asthma until the early 1990s when a more toned down version called Atrovent was developed, which basically has fewer side effects.

I remember taking Atropine as a child, and when I accidentally splashed it into my eyes I'd be blurry for a while until the medicine wore off. It was kind of annoying actually. And the only way to take it was via the nebulizer.

But these drugs are used more so as prophylactic or secondary therapy as opposed to as a rescue medicine, since now we have the miracle drug Albuterol (Ventolin) and Levalbuterol (Xoponex).

The iron lung was invented in the mid 1950s as a means of keeping kids alive who had become paralyzed by the polio-epidemic. And the evolution of this ventilator pretty much engraved the career of Inhalation Therapy, now known as respiratory therapy.

This was a negative pressure machine that required for the patient to be inside a box as it sucked the chest out and forcing the patient to breath that way. These machines were complex, and made taking care of the patient difficult.

Later positive pressure ventilators were invented, but these entailed respiratory therapists to get out their watches and calculators and use formulas to determine adequate tidal volumes, pressures, etc. These were a far cry from the microprocessor ventilators we use today that make our job easy as eating pie.

And, they make life for the patients better too, as they have, as I like to tell my patients, mini brains inside them that allows the patient to control the ventilator instead of the other way around. Now, instead of having a patient linger on the ventilator for weeks or months, he or she can be weaned in days.

When I was in respiratory school in the late 1990s, we were informed that nearly all infants born with diseases or prematurely died. By 1998, nearly 80% of infants born survived, and infants as small as 750 grams had a 40% chance of surviving. I'm certain those numbers have risen since then.

So, not only does modern medicine keep people alive longer, it allows them time on this planet that they otherwise wouldn't have had. I know I'm stating the obvious, but it's interesting to think about.

I'll put it this way: 100 years ago most of those infants would have died. It's simply amazing how far modern technology has come in helping people stay alive. It's to the point where we almost take it for granted.

It's thinking of this that makes me wonder if it is modern medicine that has caused the rapidly growing cases of diseases such as asthma as opposed to simply living in the modern, clean environment as proposed by the hygiene hypothesis.

Sure, technology up to about the mid 20th century provided some relief with knowledge that asthmatics must avoid allergens, and with the ironic asthma cigarettes, but in 2008 no asthmatic should have to live anything other than a normal life.

Basically, due to modern technology, any person with a disease that affects breathing, from asthma to COPD to cystic fibrosis has a chance to live a normal life.

And, perhaps, some day in the future this same technology will lead to an outright cure.

Modern technology basically keeps people alive long enough so that we can have statistics. That's a good thing in my book. Not only has modern technology kept me alive, it's provided me with a really cool career.

Rescue bronchodilators: Here are my unfettered answers to all of your questions about them

The following are some questions real patients have asked me recently regarding rescue bronchodilators. The answers here are my humble personal and professional opinions and nothing more.

Keep in mind that your doctor might disagree with me, and that's fine. He can overrule me whenever he wants. But, the answers here are based not just on my 10 years as an RT, but over 30 years as a chronic asthmatic who's abused more than his share of inhalers and lived to tell about it.

Q) What is the recommended dose for albuterol

A) Every 4-6 hours as needed ( no surprise here.)

Q) What if I need it more often than that

A) For most patients, I'd recommend seeing your doctor if you need it more often than every 4-6 hours, because it's a sign that your asthma or COPD is getting worse and needs to be better controlled. However, it's a relatively safe medicine, and some doctors prescribe it to be used as needed for some chronic patients.

Q) What do you think of a doctor ordering Albuterol MDI every four hours?

A) Albuterol is typically a rescue medicine, and should be taken when you are short-of-breath (SOB) due to bronchospasm. It's not going to hurt if you use it more often than when you need it, but I don't see why it would be beneficial.

Q) My doctor says Albuterol will work to prevent an asthma attack, so I should use it every four hours all day. Is this true?

A) I was taught when I was kid to take my Albuterol before I took gym class, and I did. However, it never prevented me from getting SOB. It did, however, make me feel better once I was SOB. So to answer this from my own personal experience, I'd have to say no; Albuterol does not prevent asthma symptoms. However, you can try it to see if it works for you.

There are many doctors who do believe it can be used as a preventative drug. Not only that, it states this on the Albuterol package insert. However, if it is deemed necessary that preventative medicines be taken to prevent an asthma attack, there are far more effective medicines to be using, such as Vanceril, Flovent, Atrovent, Cromolyn, Advair, etc. (this will be discussed in a later post.)

Q. I've had an Albuterol inhaler for the past 3 years. Sometimes I use it more that 10 times in a day, which is more than the prescribed frequency of every 4-6 hours. Can I use Albuterol this much and feel safe?

A. I'm treading on thin water here, but I will say yes. I find from my own personal experience as a former Albuterol abuser, and professional experience giving treatments, that Albuterol is a very safe medicine. The most common side effect is that it might make you jittery, which you probably already know if you've done it before. If you were going to have a negative reaction to the medicine, like an increase in heart rate, it would have happened already.

However, if you have other medical issues besides just COPD or Asthma, then I'd be really cautious of using too much Ventolin. I'd recommend consulting your doctor if you need to do this. Personally, though, I still think Albuterol is safe and effective in most situations where real bronchospasm is the issue.

Q. But my doctor has me on all the right preventative medicines and I'm still finding myself going through an inhaler a week. Will this have long term implicaitons on my life span?

A. I asked my doctor that exact question when I was a kid, and he told me using my inhaler was better than suffering and chancing an anoxic episode. If you absolutely have no choice than to use your inhaler more than every 4-6 hours, make sure your doctor knows about this. Chances are, he will still renew your prescription because he doesn't want you to suffer. However, he may also continue to try to adjust your other medicines to make your life easier. Sometimes, however, as in some cases of COPD or end stage COPD, this is not possible.

Let me answer this question this way. I went through an inhaler a week from the time I was 13 or 14 until about a year ago when I started taking Advair. That was 25 years. I'm getting along just fine now. Will my Albuterol abuse cut some years off the end of my life? Well, nobody really knows. Albuterol has only been around since 1987. Personally, I doubt it will.

Q. My doctor prescribed Atrovent as my rescue inhaler, what do you think of that? Should I be worried if I use it more than four times a day, because I do?

A. Atrovent is not a rescue inhaler. Atrovent takes about 20-30 minutes to work, while Albuterol, idealy, should work almost instantaneously for bronchospasm. Then again, if Atrovent works for you, then that's great. If it isn't, then I'd talk to your doctor about getting an Albuterol inhaler.

Q. Am I safe using Atrovent more often than every four hours, because I do?

A. I don't see what it would hurt. When I was in school ten years ago we were taught never to use Atrovent more often than Q4. However, some new research shows that addtitional Atrovent during an exacerbation does benefit patients. If Atrovent is working for you as a rescue drug, all the power to you. However, if you continue to be short-of-breath, you should talk to your doctor about getting an Albuterol inhaler or (ideally) adjusting your preventative medications.

Q. Can I use my Combivent more than every 4 hours?

A. Again, I don't think it would hurt you, but it's not necessary. Technically speaking, the Atrovent in this medicine shouldn't need to be taken more than every four hours. If you need to use Combivent more than every four hours, then you should talk to your doctor and get an Albuterol inhaler. You can then use your Combivent four times a day, and Albuterol in between if you get short-of-breath. (and still I'd only recommend this only if other preventative medicines weren't working.)

Q. Do you think Xoponex is better than Albuterol?

A. No. I have never noticed a difference. Original studies claimed that Xoponex was stronger than Albuterol, but I've never noticed that to be true in my real life experiences with the two drugs. Not only that, I don't think the claim that Xoponex has fewer side effects than Albuterol is true either. Recent studies have confirmed this.

However, if you have experienced cardiac side effects, or excess jitteriness or nervousness, then you might be a candidate for a trial of Xoponex, if you want to flip the bill: Xoponex costs 5-10 times more than Albuterol.

Q. What if I go through an inhaler a week?

A. Every patient is different. Do you have end stage COPD? If so, you have to do what you need to do. Do you have asthma? Then perhaps you could trial Advair. Advair worked like a miracle drug for me. I went from one inhaler a week and 600mg of theophylin twice a day down to two 300mg pills a week and 4 puffs of Albuterol a day after being on Advair 9 months.

You and your doctor have to find what works best for you. If there is no other alternative, then an inhaler a week might be the best solution.

I meet albuterol abusers at work all the time, and the majority of them are end-stage COPD patients. However, on occasion, I have met a fellow asthmatic who abuses too. Most of them think they are the only one. And, most of them think they are doing this furtively without their doctor's knowing.

Many times I walk into a patients room to give a breathing treatment and find that MDI hidden under the pillow, a sign of a true rescue inhaler abuser.

The latest research on Atrovent

As I wrote last night, we have a doctor here at Shoreline who loves to order Atrovent. Even if a patient needs a continuous treatment, it will be Duoneb, Duoneb, Duoneb, Duoneb and Duoneb. And then an hour later it will be Duoneb again.

I graduated from respiratory school in 1997, and was taught that Atrovent should ideally be given QID but never more frequently than Q4. I don't see what it would hurt to give the drug more often than that, but I also wasn't taught that it had any added benefit either.

But now we have Dr. Krane ordering it galore. She even orders Duoneb on pediatrics and Neonates. Umm, I was under the understanding that it was a drug for COPD patients mostly, or at least just adults. National Jewish Medical and Research Center verifies this.

However, I suppose I could be behind the times in my research. And, as I also wrote yesterday, so too are the other doctors behind on their research, because they still follow the old Atrovent routine.

There is one exception, though, and that would be Dr. Kipper on the floor. He's a new Internist who likes to order Q4 Atrovent treatments. My thinking about this is: why not just go with the inhaler.

So, do these doctors know something I don't? If you guys have any research on this, I'd really appreciate it. I've asked RT students that mosey through here and none of them have heard of anything. I figured if anyone would be up on the latest research it would be the RT teachers.

I did manage to find one article on the Internet "Evidence-Based Medicine for Student Health Services" by Dr. Robert J. Flaherty, MD, of Montana State University, which reports:

The addition of a single inhalation of anticholinergics (such as Ipratropium bromide) to a beta2-agonist regimen may improve lung function in children and adults with acute exacerbations of asthma treated in the emergency department. Multiple-dose anticholinergics improve lung function and may avoid hospitalisation in severe exacerbations.

Dr. Flaherty also lists some studies.

I found a second website which states the same: "(Anticholonergic) can be useful adjunct to beta-agonist in exacerbations for both adults and children-- NHLBI guidelines recommend considering in severe exacerbations." He lists several studies.

Another study from the University of Michigan that states Atrovent works on acute asthma exacerbations in children.

So, based on these reports, the excessive use of Atrovent may benefit Asthma patients, but this still doesn't get to the bottom of every treatment including Atrovent as Dr. Krane does.

Now I have absolutely no problem with giving Duoneb more often than Q4. But, if Atrovent is something that will benefit every person in need of a neb, then I want the other docs to know about this too.

Either way, if these studies are credible, then Atrovent should be given to Asthmatics, and multiple Duoneb treatments do work. If this is true, Dr. Krane appears to be up to date on her research.

If you guys know something I don't, let me know. Sometimes we can be behind the times here at Shoreline, and it's my job to catch us up.