Ipratropium Help

[EMS49393]

My fellow providers, I need some assistance.

Currently I work in Pennsylvania, and our current protocol for medication via nebulizer state we can provide albuterol 2.5 mg mixed with ipratropium 500 mcg. It also states that we can provide nebulizer treatments continuously. This is against what I was taught, and against the protocols in the past two states I have worked in and the state below me. I was taught that because ipratropium is an anticholinergic drug it is only to be given with one time, while the albuterol can be given continuously.

At this point, I'm pretty confused, and honestly I only give it one time to my patients that require that treatment because that is how I was taught, and I don't really want to dry out anyone that might already be getting dehydrated if they've been battling a wicked asthma attack for several hours.

Would one, or more, of my colleagues here please help me understand what is correct with regards to administration of this drug?

Thank you.

[tcripp]

Are you sure your continuous neb includes the iprotropium bromide and is not just albuterol?

If so, then wouldn't it be like anything else? Your protocols are there to allow you to do what you need, but you still need to monitor your patient and withhold or change treatments as necessary. It's a fine art...

[medicKristina]

So - I must reply both as a mother of a severe asthmatic and an EMT-P. I was taught up to 3. My protocols and medical director didn't even include it on our rigs. Now, as a mom, I can tell you exactly what works for my son, and that is back to back nebs of albuterol and atrovent, given simultaneously. If he gets to a point that the albuterol isn't working, then obviously, he needs something else to kick in.

As a mother who has called for assistance and been turfed, I understand the confusion. Most patients (or guardians of patients....) KNOW what works for their attacks - Although I agree that protocols say what can be done, not what HAS to be done, I think that it might also be a wise decision to ask your patient (or their guardian) what they need to help them.

I can't get my son's pediatrician to provide me an atrovent inhaler, because he FIRMLY believes in the one dose methodology, however, he has privileges at the Children's Hospital in town that will give at least 3 back to back doses as a minimum and will KEEP giving if needed. Sometimes I just shrug and remember to be an advocate - it's the best we can do most of the times. Guess where I go when I need to....and no, never has he gotten an IV for re hydration due to these severe attacks and continual use of atrovent.

Edited June 29, 2010 by medicKristina

[EMS49393]

Are you sure your continuous neb includes the iprotropium bromide and is not just albuterol?

If so, then wouldn't it be like anything else? Your protocols are there to allow you to do what you need, but you still need to monitor your patient and withhold or change treatments as necessary. It's a fine art...

That is how I am reading the protocol. I'm fairly well read, and usually have zero problem with comprehension, but I feel this protocol might need to be worded a little better for clarity.

I do what I need to do within my limits, and call for things I'm comfortable with that are outside my limits in this particular state. I'm asking more from an educational and quality assurance stand point.

I appreciate the assistance so far and hope that I hear from more people on this topic.

[Aeromedic]

From a Supervisor's standpoint, if the protocol left questions, I'd expect my staff to talk to me. Somewhat echoing what has been said before, titrate to effect. I do know of some jurisdictions, services and even individual medical directors/consulting ER Docs that have different opinions on it. In the field, when in doubt, medical direction. My protocols state that doses can be repeated without direct medical control, but to be honest, I've only ever used single doses personally. Kristina mentioned that her son needs 2 doses, and I would take it under advisement and give him a second dose if needed.

There is something really to be commended here though, asking questions. Don't be afraid to ask your Supervior/Education director/Medical Director what their preferred approach is in their service, because like you said, it can vary. I have worked for services where I had standing orders for absolutely everything in my kit (mostly because of communication difficulties due to remoteness) and others where I would have to call for gravol.

[tcripp]

I'm asking more from an educational and quality assurance stand point.

Well, then, there are several studies out there that elude to the use of continuous A+A neb treatments...so it's not far-fetched.

But, like you, I'd like to hear what others have to say.

[tskstorm]

My fellow providers, I need some assistance.

Currently I work in Pennsylvania, and our current protocol for medication via nebulizer state we can provide albuterol 2.5 mg mixed with ipratropium 500 mcg. It also states that we can provide nebulizer treatments continuously. This is against what I was taught, and against the protocols in the past two states I have worked in and the state below me. I was taught that because ipratropium is an anticholinergic drug it is only to be given with one time, while the albuterol can be given continuously.

At this point, I'm pretty confused, and honestly I only give it one time to my patients that require that treatment because that is how I was taught, and I don't really want to dry out anyone that might already be getting dehydrated if they've been battling a wicked asthma attack for several hours.

Would one, or more, of my colleagues here please help me understand what is correct with regards to administration of this drug?

Thank you.

Protocol here, is max of 3 doses of Atrovent mixed with the Albuterol, but that's also our max on Albuterol.

I'm not well versed in the long term side affects (read in hospital management of the patient after Atrovent administration) I will say here in the hospitals when I did rotations, and when we bring patients straight to the asthma room, are almost always on continuous nebulizers with Atrovent and Albuterol.

[paramedicmike]

Looking at the protocol I agree that it could be written better. It does seem to imply you can do a non stop albuterol/ipratropium neb.

You probably want to ask your medical director for some clarification on this one.

Let us know what s/he says.

Good luck.

[Kaisu]

The main event in respiratory problems is bronchoconstriction (although there are elements of excess mucus production, inflammation and brochospasm depending on the pathology involved.)

Parasympathetic stimulation produces mild bronchoconstricion in most patients, thus, administration of a parasympatholytic such as ipratroprium can be expected to produce only mild brochodilation; thus its inclusion in most protocols is limited to 2 or 3 doses.

Ipratroprium appears to inhibit vagally mediated reflexes by antagonizing action of acetylcholine specifically with muscarinic receptor on bronchial smooth muscle. However, vagal tone can be increased by as much as 50% in patients with COPD, so this can have a profound effect on the COPD patient.

It needs to be administered with the first nebulizer as it can take as long as 20 minutes to have an effect. Side effects include acute eye pain, worsening of narrow angle glaucoma, drying of bronchial secretions (a real problem if excess mucus is part of the pathology), epistaxis (because of drying of membranes)and urinary retention, (a problem with renal patients.)

Like everything else we do, there is no cookbook. When I first started as a medic, I was looking for definitive answers. Tell me what to do and I will memorize it and do it. There are none. The more we learn, the more our individual judgement and clinical knowledge comes into play.

As with others, if I have a reasonably intelligent parent that has in depth knowledge of their child's responses to treatments, I would certainly give it more weight in my treatment than the protocol that says only 1 or 2 ipratroprium. Protocols are guidelines. If you deviate from them, be sure you have a good reason for it. Generally, deviation from protocol when you have a good outcome is never questioned. If you deviate and screw up, be prepared to defend your decision.

[BushyFromOz]

coming from the country with highest rate of asthma per capita.....

To start off with, what crapmagnet said

Metered dose inhalers are recommended by the peak clinical body here in regard to asthma and COPD. Several studies here have show that for pts who still have adequate air movement, PMDI's when used with a spacer aerosolize (is that even a word?) the drug better and depisit it to the smaller airways more effectively than nebulised treatments as the largwe droplets of nebulised drugs ends up binding to mucous in the upper respiritory tract and goes no where. PMDI's are given at 4 puffs ever 4/60 until resolution of symptoms by the pt or by us.

For pts with inadequate air movement, the salbutamol + atrovent already stated here is whats recommended, though its via a nebuliser and we use an initial dose of 5mg salbutamol and 500mcg of atrovent, as this is supposed to give a better ratio of drug delivered to mucouse membranes and drug delivered to small airways. each dose after that is 2.5mg of salbutamol. Pts with an exacerbation of COPD go straight to a nebulised Rx as these patients get atrovent no matter what their presentation.

For the intensive care guys, dexemethesone and IV salbutamol infusions is something that they can throw in for those who are refractory to treatment. This guideline here changes constantly as the info is updated, in 2 years i have seen this guideline changed twice in its detail (not necessarily in drug regime)

Asthma Council of Australia

If you deviate and screw up, be prepared to defend your decision.

The problem from my observation, i believe doesn't seem to be hammering the drugs in, moreso inexperience people (and i don't mean the OP, just in general) know the drug regimes but don't know when to stop. You can hammer away with the salbutamol at 5/60 continuously if you want, and many do because the pt still has an exp. wheeze, but they fail to take in the whole of the pts respiratory function. HR of 100, Sats of 95, Exp. wheeze, RR26 but sitting up and talking full sentences, and some mildly distressed, is not going to cop nebs continuously until we reach the hospital - way to make someone anxious again, give em 30-40mg of salbutamol they didn't need.

As a side note, i absolutley hate it when people move these patients without putting in a IV on the premise of "saving time", really pisses me off!