Albuterol MDI

[urge]

Advertisement - Members don't see this ad

Is there a role for it in the anesthesia cart? IV beta agonists are more effective in my experience. Should we get rid of it?

I would much rather use that space for racemic epinephrine for the rare but rather dramatic upper airway edema events.

Try finding racemic epi in your hospital in less that 10 min at night. Good luck.

What say you?

 

[Gern Blansten]

Is there a role for it in the anesthesia cart? IV beta agonists are more effective in my experience. Should we get rid of it?

I would much rather use that space for racemic epinephrine for the rare but rather dramatic upper airway edema events.

Try finding racemic epi in your hospital in less that 10 min at night. Good luck.

What say you?

We still use it at our place. It "seems" to help in many cases, although, if I want "2 puffs" I always give about 20 because I assume most of it just gets stuck in the ETT or circuit. I just pop it into a 60mL syringe and hook it up to the CO2 port on the Y-piece and start pushing during inspiration. Hard to always know if it really works or if it just makes us feel a bit better about it. But, I have convinced myself it works most of the time and therefore, seems worth it to me. Most people I have encountered use it when needed.

 

[chessknt]

Is there a role for it in the anesthesia cart? IV beta agonists are more effective in my experience. Should we get rid of it?

I would much rather use that space for racemic epinephrine for the rare but rather dramatic upper airway edema events.

Try finding racemic epi in your hospital in less that 10 min at night. Good luck.

What say you?

You use IV beta agonists in asthmatics having bronchospasm? Every clinical guideline in existence I am aware of recommends inhaled beta agonists. GINA has a grade A guideline stating not to use IV beta agonists for acute asthma exacerbation as well so I would think, at least in the fairly common condition of asthma, albuterol MDIs should absolutely be available for emergency use.

 

[urge]

You use IV beta agonists in asthmatics having bronchospasm? Every clinical guideline in existence I am aware of recommends inhaled beta agonists. GINA has a grade A guideline stating not to use IV beta agonists for acute asthma exacerbation as well so I would think, at least in the fairly common condition of asthma, albuterol MDIs should absolutely be available for emergency use.

No idea what GINA was until now.

My AI Fu says GINA does not cover intraop management of bronchospasm in intubated patients. That’s mostly for the patients at home (no IV) or at worst ED (not intubated).

 

[chessknt]

No idea what GINA was until now.

My AI Fu says GINA does not cover intraop management of bronchospasm in intubated patients. That’s mostly for the patients at home (no IV) or at worst ED (not intubated).

Do you think there is a better body of evidence to deviate from the consensus guidelines for the management of acute asthma exacerbation? People show up to the ed in extremis with asthma and get intubated and still get albuterol pumped into the vent circuit instead of pushed IV.

 

[urge]

Do you think there is a better body of evidence to deviate from the consensus guidelines for the management of acute asthma exacerbation? People show up to the ed in extremis with asthma and get intubated and still get albuterol pumped into the vent circuit instead of pushed IV.

Is there a guideline that covers intraop intubated patients having bronchospasm? That would be more relevant.

Albueterol doesn’t work if you are having a hard time ventilating. And the administration through the end tidal port with a 60ml syringe doesn’t create the small droplets to travel far down the airway.

 

[chessknt]

Is there a guideline that covers intraop intubated patients having bronchospasm? That would be more relevant.

Albueterol doesn’t work if you are having a hard time ventilating. And the administration through the end tidal port with a 60ml syringe doesn’t create the small droplets to travel far down the airway.

I would be willing to bet if there is an actual guideline it doesn't recommend IV beta agonists over inhaled ones.

Albuterol absolutely does work if you are having a hard time ventilating, it has been a cornerstone of saving lives from asthma exacerbation for decades. How do you think ER/ICU manage severe vented asthmatics?

 

[urge]

I would be willing to bet if there is an actual guideline it doesn't recommend IV beta agonists over inhaled ones.

Albuterol absolutely does work if you are having a hard time ventilating, it has been a cornerstone of saving lives from asthma exacerbation for decades. How do you think ER/ICU manage severe vented asthmatics?

Over means what? Does it mean first line, or does it mean the stuff that works when first line failed?

We both know albuterol would be considered first line by most physicians.

A far fewer number of physicians who have treated severe bronchospasm in intubated patients know IV beta agonists is the stuff that works after albuterol failed.

Which is the point of my thread. Why bother with the stuff that is inferior?

It’s like neostigmine vs sugammadex.

 

[urge]

We still use it at our place. It "seems" to help in many cases, although, if I want "2 puffs" I always give about 20 because I assume most of it just gets stuck in the ETT or circuit. I just pop it into a 60mL syringe and hook it up to the CO2 port on the Y-piece and start pushing during inspiration. Hard to always know if it really works or if it just makes us feel a bit better about it. But, I have convinced myself it works most of the time and therefore, seems worth it to me. Most people I have encountered use it when needed.

If you don’t know if it worked then it must not have made a difference. Let’s say peak pressures and volumes didn’t change. What was the point then? A drug given for acute bronchospasm should have objective measurable changes in ventilation.

 

[chessknt]

Over means what? Does it mean first line, or does it mean the stuff that works when first line failed?

We both know albuterol would be considered first line by most physicians.

A far fewer number of physicians who have treated severe bronchospasm in intubated patients know IV beta agonists is the stuff that works after albuterol failed.

Which is the point of my thread. Why bother with the stuff that is inferior?

It’s like neostigmine vs sugammadex.

You are advocating for disregarding a first line therapy (for asthma at least) with an overwhelming body of evidence behind it for something that is essentially unproven because of anecdotal experience. I don't think that is a great idea and at a minimum wouldn't advocate from removing the option of following it (in an emergent situation) from everyone else who uses that cart.

 

[Gern Blansten]

If you don’t know if it worked then it must not have made a difference. Let’s say peak pressures and volumes didn’t change. What was the point then? A drug given for acute bronchospasm should have objective measurable changes in ventilation.

Audible decrease in wheezing. The unknown comes from, would it have gotten better on its own, with the volatile anesthetic?

 

[urge]

You are advocating for disregarding a first line therapy (for asthma at least) with an overwhelming body of evidence behind it for something that is essentially unproven because of anecdotal experience. I don't think that is a great idea and at a minimum wouldn't advocate from removing the option of following it (in an emergent situation) from everyone else who uses that cart.

IV beta agonists are unproven?

The Ped crisis cheat sheet from SPA advocates for IV beta agonists for severe bronchospasm. They don’t advocate for albuterol MDI in severe cases (because it doesn’t work).

 

[urge]

Besides not really working on intubated patients, here is another nugget of truth for you:

 

[chessknt]

IV beta agonists are unproven?

The Ped crisis cheat sheet from SPA advocates for IV beta agonists for severe bronchospasm. They don’t advocate for albuterol MDI in severe cases (because it doesn’t work).

I don't treat peds so I wouldnt know but that picture (not sure what SPA advocates is) doesn't mention IV albuterol at all and actually says to use the inhaled version....

This is an odd hill to die on. You are allowed to have your anecdotal beliefs but data and physiology strongly support inhaled SABA mechanism. Here is a a paper if you are interested in why Lung pharmacokinetics of inhaled and systemic drugs: A clinical evaluation - PubMed

Inhaled delivery results in vastly higher concentrations than IV delivery which is why it works better is the short version. Yes in severe bronchospasm the physiology is going to be different but hypoxic vasoconstriction also happens in that scenario so it isn't like the IV mechanism is completely unaffected either and, again, the data and practice standards across all other aspects of asthma management support inhaled use. If you skipped inhaled SABA and just gave IV with a bad outcome I imagine that would be immediate game over in a lawsuit.

 

[urge]

I don't treat peds so I wouldnt know but that picture (not sure what SPA advocates is) doesn't mention IV albuterol at all and actually says to use the inhaled version....

This is an odd hill to die on. You are allowed to have your anecdotal beliefs but data and physiology strongly support inhaled SABA mechanism. Here is a a paper if you are interested in why Lung pharmacokinetics of inhaled and systemic drugs: A clinical evaluation - PubMed

Inhaled delivery results in vastly higher concentrations than IV delivery which is why it works better is the short version.

Epinephrine and ephedrine come to mind.

Keep minimal stuff in drawer that actually works.

 

[CopaceticOne]

IV beta agonists are unproven?

The Ped crisis cheat sheet from SPA advocates for IV beta agonists for severe bronchospasm. They don’t advocate for albuterol MDI in severe cases (because it doesn’t work).

It literally says in that screen capture to give albuterol puffs in their top down steps of what to do.

 

[urge]

It literally says in that screen capture to give albuterol puffs in their top down steps of what to do.

I am aware.

But if it is severe, what does it recommend?

If albuterol cannot treat severe bronchospasm why bother?