DuoNeb

[VentMedic]

There are several nebulizers on the market now to give improved delivery. AeroEclipse for non vented pt and Aerogen for vents come to mind. For MDIs, a spacer (Aerochamber) should always be used in any situation but definitely in emergencies. This has been proven in many labs to provide up to 60% better deposition of particles. Pt usually notice the difference.

Using just Duoneb limits you as to the recommended dosage may easily be exceeded for Atrovent. Pharmacies in hospitals and accreditation boards are now monitoring this closely and suggesting a medication error report be filed for each occurence. If a physician wants more Duoneb than q4 hours, they must sign an exception for responsibility.

Albuterol gives you more options for high doses...5 mg of the concentrated is used many times before starting a 10 - 25 mg/hour continuous.

[tniuqs]

There are several nebulizers on the market now to give improved delivery. AeroEclipse for non vented pt and Aerogen for vents come to mind. For MDIs, a spacer (Aerochamber) should always be used in any situation but definitely in emergencies. This has been proven in many labs to provide up to 60% better deposition of particles. Pt usually notice the difference.

Using just Duoneb limits you as to the recommended dosage may easily be exceeded for Atrovent. Pharmacies in hospitals and accreditation boards are now monitoring this closely and suggesting a medication error report be filed for each occurence. If a physician wants more Duoneb than q4 hours, they must sign an exception for responsibility.

Albuterol gives you more options for high doses...5 mg of the concentrated is used many times before starting a 10 - 25 mg/hour continuous.

Firstly welcome to the City VentMedic.

Yes, have seen the AeroEclipes unfortunatly those in "Extremus" have some may difficuly in triggering and the mouthpiece delivery is not the "most optimal" in my opinion for those patients in an EMS setting, as the patient has to make a seal.

What I have used is a device made @ Bedside with 2 extention tubes inserted into the holes of the normal SVN mask, (STAR WARS) is what we called it also increases FiO2 (in theory and proven @ bedside) by increasing the reservoir size of the mask ~ 100 mls per breath, I have mentioned this in prior posts, there has got to be a better mousetrap out there ?

For delivery with MDI the areochamber is mandatory, (again bedside testing) that I have been involved indicated that with MDI only just ~ 20% of patients were actually recieving a dose, no radioactive isotopes were used in testing as with initial trials this just clinical observation by experianced practioners.

My question was when the primary findings for MDI the efficacy, deposition and isotope tracing (by Galaxo, if memory serves me correctly for the MDI) was that the SVN delivery method in the studies never did "clearly identify" whether mask, mouthpiece or other means was used.

In ancient times a "T" or "Y' was placed on the O2 line downstream from the SVN and pt.s were instructed to use this thumb control to optimize delivery (only during inspiration) old idea but cost effective.

cheers

ps j/k there akroeze, more Mars for me.

[VentMedic]

Thank you for the welcome.

I personally found the Circulaire with 5 - 10 mg Albuterol undiluted for pediatrics and some adults useful.

The AeroTee got some decent reviews also. However, two of the studies were misleading and were defended by company reps in RT publications.

I rarely give a treatment by mask. Mouthpiece for as long as they can cooperate it. I also get an idea for their inspiratory force and know if a tube may be in their future.

Pet Peeve; people that tape the tube of the nebulizer so that it blows back toward the pt's face.

These meds should not go into the eyes. Nor, should any of the bacteria that is present in the mouth, throat or lungs go toward the eyes.

[OzMedic]

Tniuqs, I also worry about the use of adrenaline in these patients to early in the piece. It should be reserved for pre-arrest patients in my opinion, especially in older patients. If a patient is in extremis with minimal air movement I tend to stick with the high concentration oxygen via NRB and go straight to IV salbutamol (albuterol). It tends to be a bit kinder to the heart than adrenaline. I switch back to nebulised as soon as the patient starts moving some air. I also administer some IV steroids as early as practical so they begin to work sooner, not much benefit pre-hospital but will benefit the patient earlier. Sorry I realise this is not related to the original subject of this thread.

[tniuqs]

Tniuqs, I also worry about the use of adrenaline in these patients to early in the piece. It should be reserved for pre-arrest patients in my opinion, especially in older patients. If a patient is in extremis with minimal air movement I tend to stick with the high concentration oxygen via NRB and go straight to IV salbutamol (albuterol). It tends to be a bit kinder to the heart than adrenaline. I switch back to nebulised as soon as the patient starts moving some air. I also administer some IV steroids as early as practical so they begin to work sooner, not much benefit pre-hospital but will benefit the patient earlier. Sorry I realise this is not related to the original subject of this thread.

Yes a bit off topic but I think some valuable information... and don't PM the DEAN aka ASY or we are all going to get the strap...

I think IV "salbutamol" is out of scope of practice for most here, we did have it in some services here but wthout a pump your shooting CRAPS, the one round dose lost favour cause Pts get a wooge, drop pressures and get really pale in color!

"ROIDS" yuppers early vs late, they work on everything...but I was no them in 1994...no wonder I am still LOOPY, sucks to come off big time, ACS.

Quoting VentMedic:

I rarely give a treatment by mask. Mouthpiece for as long as they can cooperate it. I also get an idea for their inspiratory force and know if a tube may be in their future.

I am way too lazy for that.

Pet Peeve; people that tape the tube of the nebulizer so that it blows back toward the pt's face.

These meds should not go into the eyes. Nor, should any of the bacteria that is present in the mouth, throat or lungs go toward the eyes.

Good point !

cheers

[Dustdevil]

In ancient times a "T" or "Y' was placed on the O2 line downstream from the SVN and pt.s were instructed to use this thumb control to optimize delivery (only during inspiration) old idea but cost effective.

Ancient?

I thought that was still the state of the art! :oops:

I thought the Army was just too cheap to buy the nebs with the Y adapters on them, lol!

[1EMT-P]

There are several options when treating patients with Asthma & COPD... The AeroChamber is a good one if your using MDI's. It was designed to boost the delivery of medication into the lungs... Another good option is the PARI Nebulizers, they have been show to be very effective & reliable.

I had an older Pulmonologist tell me that the newer medications are not really any better than the older ones that they are just more expensive... He still uses Albuterol, Alupent (Metaproterenol), Brethine, Dexamethasone & Theophylline.

[ffmedic9588]

soy bean thats right AZCEP thanks for the clarification. Great topic and chat.

[VentMedic]

You gotta "sell" the medication's effectiveness to the pt. When Xopenex first came out, we didn't see it work faster on the any one pt more than Albuterol. But when you get a hard core COPDer depressed about their long term status, used Albuterol forever and isn't feeling good about it anymore.... Well here is the new and improved wonder drug :wink: ..... No matter what your real thoughts are...with the right psych mode, this might work. Of course, FEV1 studies are not done that often in pre-hospital. But in the PFT labs, the right attitude and med can produce results that can be seen.

With an aerochamber, other familly members can be taught to assist the pt until EMS arrives. The 5 second holding chamber allows some medication to be inhaled. Don't believe me...check out the literature for albuterol administration on cats (house pets not lab rats) with a similar aerochamber product. 8)

In EMS and ER we usually power the neb off of O2...nice hyperoxic state of feeling "better". Even if powered off of air from a tank or wall outlet, the extra flow will give them an "improved" feeling momentarily. If you ever watch a long time commercial compressed air neb user (serious COPDer)...they draw long and deep and do a little glottic closure movement (pursed lips or accessory muscle usage at the end. This gives a little extra "PEEP" action. The portable devices run at a fixed 5 -6L/m flow. The COPD pt learns to compensate overtime to get that same higher flow effect sub - glottic.

Another pet peeve: telling a pt that a nebulizer works better than an MDI.

If a nebulizer is what you first line protocol calls for, tell them you're trying different things and providing O2 with the med at the same time...if they ask, most don't.

MDIs are rescue inhalers and that may be all the pt can carry to work. Planting the idea that their MDI doesn't work as good may set them up for failure during their next asthma/COPD attack.

[tniuqs]

You gotta "sell" the medication's effectiveness to the pt.

Another pet peeve: telling a pt that a nebulizer works better than an MDI.

It sounds as if your contradicting yourself a touch? but agreed some good intel, thanks.

I have never seen a study comparing the 2 methods in the acute asthmatics and in the EMS setting it is unlikely you would find a compresser onboard many rigs. In fact check local protocols as there has benn a case where compressed air was used instead of O2 resulting in a court actions.

ok yea can't say "pet peeve" here!

cheers