magnesium for COPD

[zzyzx]

Is anyone familiar with using mag for severe COPD exacerbation? (I'm familiar with its use in asthma.)

[tcripp]

Is anyone familiar with using mag for severe COPD exacerbation? (I'm familiar with its use in asthma.)

While I've not had the opportunity yet to use this drug, we do have it as an option in our SOCs for patients in severe bronchospasm / extremis. We are a rural service and if we need to drive to a higher level of care, it would be beneficial to get this drug on board early. (Depending on where we are in county and traffic in the big city, our drive can be 1 - 1.5 hours.)

I did have a respiratory failure patient not too long ago, but opted to drive to the closest facility for stabilization and then the patient was flown out from there. Otherwise, that would have been my first admin of this drug.

[1EMT-P]

Yes, Magnesium is very important, it plays a role in many physiologic reactions. It is used for Cardiac, Diabetic, Obstetrical & Respiratory problems.

[46Young]

Is anyone familiar with using mag for severe COPD exacerbation? (I'm familiar with its use in asthma.)

From emedicine.medscape.com:

<LI>Magnesium: Though controversial, administration of magnesium is thought to produce bronchodilation through the counteraction of calcium-mediated smooth muscle constriction. The addition of intravenous magnesium is now considered to have class B evidence supporting its use in difficult and life-threatening exacerbations.

While I've not had the opportunity yet to use this drug, we do have it as an option in our SOCs for patients in severe bronchospasm / extremis. We are a rural service and if we need to drive to a higher level of care, it would be beneficial to get this drug on board early. (Depending on where we are in county and traffic in the big city, our drive can be 1 - 1.5 hours.)

I did have a respiratory failure patient not too long ago, but opted to drive to the closest facility for stabilization and then the patient was flown out from there. Otherwise, that would have been my first admin of this drug.

I've seen mag work really well with tight asthmatics. You'll like it to, I think.

Do you have a combined protocol for reactive airway disease? That's what it sounds like you're describing. We had a blanket protocol ourselves until 2009, where we split asthma and COPD into their own protocols. For us, the COPD exac. gets only 5 mg albuterol/5mg atrovent, a repeat of one/one, and 125 mg of solu-medrol. The asthmatics can get nebs, solu-medrol, mag, and epi. We also have racemic epi, 5 mg epi 1:1000 undiluted via neb on S.O. for peds croup/epiglottitis.

[usmc_chris]

We also have racemic epi, 5 mg epi 1:1000 undiluted via neb on S.O. for peds croup/epiglottitis.

Not to change the subject, but a minor educational point. Racemic epinephrine is NOT simply nebulized 1:1000 epinephrine. They are different drugs. Closely chemically related, but not the same pharmaceutical. What you describe is ordinary 1:1000 epinephrine placed in a nebulizer. There is some benefit to doing this as well, but it is not technically racemic epinephrine.

[46Young]

Not to change the subject, but a minor educational point. Racemic epinephrine is NOT simply nebulized 1:1000 epinephrine. They are different drugs. Closely chemically related, but not the same pharmaceutical. What you describe is ordinary 1:1000 epinephrine placed in a nebulizer. There is some benefit to doing this as well, but it is not technically racemic epinephrine.

Thanks for the observation. I honestly never checked into it. My protocols say racemic epi, and say to admin. as I said in the above post. Is racemic epi in a different suspension then IV epi? What is true racemic epi? I've recently caught nasal epi in one of our drug bags, so I sent out an e-mail to EMS admin. Several other units also had 30ml vials of nasal adrenalin 1:1000. Apparently the pharmacy dropped the ball on that one, along with the field providers that didn't bother reading the label, either.

[croaker260]

In my experiance and research, Mag is not really useful or indicated in COPD/obstructive airway disorders, whereas is use in Asthma/reactive airways is relatively better understood and accepted.

We to have a combined protocl for COPD and ASTHMA, but we also state that mag is for asthma disorders only.

[46Young]

In my experiance and research, Mag is not really useful or indicated in COPD/obstructive airway disorders, whereas is use in Asthma/reactive airways is relatively better understood and accepted.

We to have a combined protocl for COPD and ASTHMA, but we also state that mag is for asthma disorders only.

That's pretty much the gist of it. In your dept, the medics probably know why certain meds will be used only for asthma, and not COPD. The problem is, in other systems, the medics don't know any better than to follow the cookbook. They think that if they don't give everything in the protocol, they'll get in trouble. We had providers that actually pushed epi and started a mag drip on a COPD exacerbation.

[usmc_chris]

Thanks for the observation. I honestly never checked into it. My protocols say racemic epi, and say to admin. as I said in the above post. Is racemic epi in a different suspension then IV epi? What is true racemic epi? I've recently caught nasal epi in one of our drug bags, so I sent out an e-mail to EMS admin. Several other units also had 30ml vials of nasal adrenalin 1:1000. Apparently the pharmacy dropped the ball on that one, along with the field providers that didn't bother reading the label, either.

I'm not a pharmacist, but based on a quick Google search, I think I can give you a general idea of the difference. True Racemic Epinephrine is a 50:50 mixture of the "left" (active) and "right" forms of the epinephrine isomer. Some of the pages I looked at stated that simply givng L-Epinephrine (what we ordinarily carry), at 1/2 the strength of what you would give Racemic Epi at, is equivalently effective in the treatment of croup. I THINK, and somebody please correct me if I'm wrong, that the benefit of true Racemic Epi is that there is minimal systemic absorption - we get the relaxation of smooth muscles in the airway that we are looking for, without the systemic alpha and beta effects (increased heart rate, increased BP, etc). Somebody with a better understanding of pharmacology please chip in here! I'm just as curious - I don't really truly understand the difference well, I just know there IS a difference.

[D.P.Gumby]

Some additional input on the epi issue. There is at least one study that has directly examined the use of racemic versus L-epinephrine for croup:

http://www.ncbi.nlm.nih.gov/pubmed/1734400

Although it is a RCT, unfortunately it is small and not of the best quality: I don't think it can confirm the non-superiority of racemic epi, but it probably does establish L-epi (the more readily available form) as a plausable treatment. A quick look didn't turn up any better literature, though it certianly may exist.

I think the summary above was good, and from what I've seen the proposed benefit of racemic epinephrine is indeed minimization of side effects. I have to say, I've never seen a good explanation of this purported benefit, and it doesn't seem to make too much sense.

As the L-epi form is generally considered the only active enantiomer (racemic epi is 50/50 of the L and R enantiomers), the idea that racemic epi would somehow minimize effects doesn't make sense. If R-epi is not physiologically active, it's inclusion in the administration should have no effect. If R-epi is active, presumably its action is similar to l-epi, and we would expect a similar side effect profile.