MDI for bronchospasm

[NumTacos]

Probably dumb question, but I couldn’t quickly find a lot of literature about it, gave up quickly due to me being a bit ADHD. Had a female smoker for routine Ortho bronchospasm on induction. It was pretty manageable after deepening anesthetic and some albuterol puffs down the ETT. For a lot of these players who spasm, I give subq terbutaline after it saved my ass once (I think). Usually give decadron too if indicated. When I was squirting albuterol down the tube, the OR nurse chimed in and asked if I wanted one of those “thingies” that respiratory uses. I assumed that me of those fancy in line nebulizers they use in the ICU. Think I did that a LONG time ago when I was fresh out of residency, but it’s just too time consuming to find all that stuff. I’ve also previously used 60 cc syringes in the past to administer albuterol via ETT, but in my training, most of my attendings would simply disconnect and use a MDI in the cart to squirt 5-6 puffs down the hatch. This is kind of what I have done for my whole career, luckily I haven’t had anything I couldn’t handle with basic treatment. Anyone think it should be administered differently?

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[Ronin786]

MDI's are intended to make the albuterol aerosolized so it doesn't just sit in the mouth and throat. With the ETT going straight to the lungs, any way that means the albuterol isn't just coating the ETT seems like it would be effective to me.

 

[vector2]

MDI's are intended to make the albuterol aerosolized so it doesn't just sit in the mouth and throat. With the ETT going straight to the lungs, any way that means the albuterol isn't just coating the ETT seems like it would be effective to me.

But when an awake person uses an MDI they are actively inhaling which pulls along the aerosol and then breath holding at max inspiration. When I use an MDI on a pt (thru disconnected ETT) they're paralyzed. Some of it probably sticks which is why I give like 20 puffs.

If one is using an inline adapter and giving during inspiration then you're probably right that the dose doesn't need to be crazy.

 

[NumTacos]

But when an awake person uses an MDI they are actively inhaling which pulls along the aerosol and then breath holding at max inspiration. When I use an MDI on a pt (thru disconnected ETT) they're paralyzed. Some of it probably sticks which is why I give like 20 puffs.

If one is using an inline adapter and giving during inspiration then you're probably right that the dose doesn't need to be crazy.

That’s what I do, give a ton of puffs, and I think this is why everyone in the room was looking at me weird. It’s what I was taught, sounds like most people do the same. Thanks for the reply.

 

[abolt18]

But when an awake person uses an MDI they are actively inhaling which pulls along the aerosol and then breath holding at max inspiration. When I use an MDI on a pt (thru disconnected ETT) they're paralyzed. Some of it probably sticks which is why I give like 20 puffs.

If one is using an inline adapter and giving during inspiration then you're probably right that the dose doesn't need to be crazy.

I usually do this. Inline adapter, give puffs of albuterl as I give a breath, then try to hold the valsalva. Repeat a couple times.

Supposed to shake the MDI between puffs, and prime it with 2-3 puffs before you use it the first time as well.

 

[kidthor]

I end up just putting 10-12 puffs straight down the ETT because when I want to give albuterol I want to give it now. If I can find the fancy adaptor down the line then I might look for it.

I'm quick to give a small dose of epinephrine if albuterol didn't do the trick.

I also occasionally use subcut terbutaline (as noted by OP). Most often I'll give it to smooth out recurrent bronchospasm on emergence.

 

[abolt18]

I end up just putting 10-12 puffs straight down the ETT because when I want to give albuterol I want to give it now. If I can find the fancy adaptor down the line then I might look for it.

I'm quick to give a small dose of epinephrine if albuterol didn't do the trick.

I also occasionally use subcut terbutaline (as noted by OP). Most often I'll give it to smooth out recurrent bronchospasm on emergence.

I'd have a MUCH harder time finding terbutaline than the adapter! They stock our cart with the adapter next to the Albuterol.

 

[DrOwnage]

I end up just putting 10-12 puffs straight down the ETT because when I want to give albuterol I want to give it now. If I can find the fancy adaptor down the line then I might look for it.

I'm quick to give a small dose of epinephrine if albuterol didn't do the trick.

I also occasionally use subcut terbutaline (as noted by OP). Most often I'll give it to smooth out recurrent bronchospasm on emergence.

What dose of terb are you giving for that?

 

[vector2]

What dose of terb are you giving for that?

I usually give 250 or 500 mcg SQ. I've also given one or two hundred mcg IV without any issues

 

[Maz777]

If it's legit bronchospasm, low-dose epi and call it a day. I honestly don't think albuterol does anything for significant bronchospasm nor prevents it any significant way. I think it just makes us feel better that we did something. The best therapeutic maneuver (after the acute spasm has resolved) to prevent it from happening again is to remove the noxious stimulus (ETT).

 

[Iso4ane]

Take the mouthpeice off, and it should fit in line with your circuits. Add a Combivent or Albuterol Neb treatment inside.

 

[woopedazz]

For scary bronchospasm just give adrenaline IV +/- down ETT
For everything else just use an adaptor and give 6-10 pumps of whatever. If you can't find the adaptor you can also do silly things like give via HME filter/in syringe form/down the side-stream/other MacGyver techniques.

 

[FiO2@21]

For one I had dealt with: IV mag, epi for the very acute term. Glyco and steroids given for post-op course. Didn't bother with ETT epi. I did the 50-60 cc syringe thing with the MDI albuterol. It's what I do for bad asthmatics and COPDers in general to ward off evil spirits.

But with severe bronchospasm I was skeptical that this would be very helpful. So I called RT to the OR and just had them come give me a nebulizer they use in the unit and gave some DuoNeb. It helped that it was 2 pm instead of 2 am, so there was a whole gaggle of RTs available. It messed with the gas sampler a little, the anesthesia machine thought I was using halothane for a few minutes. But I kept the sevo a bit higher anyway so I wasn't worried about awareness.