Albuterol in CHF patients

[firefighter523]

I am a medic student who was on 2 calls (different weeks), both CHF, resp distress. Both had a history of CHF, and had the tell tale signs, peripheral edema, tachypnea of about 32 times a minute, with an SPO2 of 80%, ashen in color. I couldn't hear anything in their lungs because they just didn't have the volume to hear anything. I just wanted to know what your thoughts were to give albuterol first to open them up, and treat what you hear. Keep in mind, these patients had a documented history of CHF in their charts. Our protocols have albuterol in it, on command only. Is that the reason it could be in the protocol? It worked perfectly in the first call, then we treated the CHF, (nitro, lasix, CPAP). The second senario, I got yelled at, (different medic) he stated that it albuterol isn't a diagnostic aid for CHF. Please help out.... I am confused...

[Ace844]

I am a medic student who was on 2 calls (different weeks)' date=' both CHF, resp distress. Both had a history of CHF, and had the tell tale signs, peripheral edema, tachypnea of about 32 times a minute, with an SPO2 of 80%, ashen in color. I couldn't hear anything in their lungs because they just didn't have the volume to hear anything. I just wanted to know what your thoughts were to give albuterol first to open them up, and treat what you hear. Keep in mind, these patients had a documented history of CHF in their charts. Our protocols have albuterol in it, on command only. Is that the reason it could be in the protocol? It worked perfectly in the first call, then we treated the CHF, (nitro, lasix, CPAP). The second senario, I got yelled at, (different medic) he stated that it albuterol isn't a diagnostic aid for CHF. Please help out.... I am confused...[/quote']

"firefighter523,"

Good question. In my practice and education I have found this to always bring out an interesting discussion. Even after spending along period of time in a hospital and getting to know a bunch of docs well I have found quite the variance in clinical RX's and opinions on this. I hope what follows here will help your confusion some and clear it all up abit. Also you can do a search as both rid and I have posted "teaching posts," on CHF.

1.) One of the main reasons we don't give a B agonist in an acute presentation of CHF has 2 parts. The literature and evidence backs up these points.

A.) It increases MIO[sub:fc234536bd]2[/sub:fc234536bd] demand through chronotropy. This can cause an infarct, increase the pt's hypoxia, and or worsen an existing infarct-ischemia.

B.) It generally isn't a good idea to give a B agonist to a pt who may soon recieve B blockers.

Now having said this one of the docs who I have had the pleasure of getting to know and has been an ER-intensivist MD for 30 yrs stated to me that he likes to use it in the acute on chronic presentation with little to no possibility or clinical suspicion of MI & in the case where the pt has extremely poor tidal volumes. His ratioanle for this is that the short acting effect of the Albuterol will definately cause an increase in rate and MIO[sub:fc234536bd]2[/sub:fc234536bd] demand. Yet it will also Broncho dialate and help improve both the pt's ability to ventialte appropriately ( i.e: TV-Fi0[sub:fc234536bd]2[/sub:fc234536bd]), and give you the ability to treat their CHF with the measures you mentioned.

Other doc's I've worked with disgree and don't use it at all prefering to use other measures for reasons A & B above. You should note though that these are MD's and they have their own liscence and thus some clinical leeway with which to work in. As always, YMMV; and you should know your areas practice parameters, policies, prtocols, etc... When in doubt, call Med con. Be careful as if certain things are mandated in yoiur protocols you are compelled to do them as they are practice minimums.

Next I have found that there is an institutional dogma in which Medics get taught that Albuterol will cause a pt to "flash," I am told this is not the case. As it has been explained to me anecdotally by the head of Pulomonary Medicine at RI Hosp., he states that " The Albuterol doesn't have a great effect on the terminal airways it works mostly on the larger ones (i.e.: in the bronchus) and this these concerns that the pt will flash are usually due to (A & B above) which is a secondary effect of the Albuterol admin. You are merely increasing the potential space for that fluid. In 20+ years of practice I've never seen that. You don't need to worry about that, just becareful and know what your protocols compel you to do" THERE IS A BIG DIFFERENCE BETWEEN USING ALBUTEROL KNOWINGLY IN AN ACTUE CHF PT; VS: USING IT TO DIAGNOSE OR TO DIFFERENTIATE IT FROM ANOTHER DDX, ONE IS OK CLINICAL PRACTICE THE OTHER IS NEGLIGENT AND CAUSES HARM TO YOUR PT!!!

Here are the links to "RID'S & ACE'S TEACHING THREADS," ON THIS SUBJECT:

http://www.emtcity.com/phpBB2/viewtopic.php?t=1296

http://www.emtcity.com/phpBB2/viewtopic.php?t=1331

http://www.emtcity.com/phpBB2/viewtopic.php?t=2639

http://www.emtcity.com/phpBB2/viewtopic.php?t=2496

http://www.emtcity.com/phpBB2/viewtopic.php?t=2402

http://www.emtcity.com/phpBB2/viewtopic.php?t=2639

http://www.emtcity.com/phpBB2/viewtopic.php?t=2497

http://www.emtcity.com/phpBB2/viewtopic.php?t=1564

In closing there is another thread which albeit old has some good info here::

http://www.uhmc.sunysb.edu/emed/paramedic/.../1996/1199.html

here's some quotes which are relevant:

(Mark DuFine @ M.D; DrMarkJD@aol.com

Mon, 9 Dec 1996 13:33:43 -0500)

As I instruct my medics, it would be a dangerous venture to give

albuterol. You are going to increase the heart rate. This in turn requires

increase in the oxygen demand because of the work the heart is doing. The

patient you are dealing with has a huge O2 demand as it is. Are you

attempting to treat a symptom or the root of the problem?

Your initial needs in this case is to give the patient supplemental O2,

a diuretic, some preload reducers (Nitro, morphine). You may wish to

consider the possibility of dopamine to help the BP as well as help renal

perfusion.

[web:fc234536bd]http://www.emedicine.com/emerg/topic108.htm[/web:fc234536bd]

Hope this helps,

ACE844

[Ridryder 911]

First you need to learn about CHF vs. Asthma.. etc. There are many good posts on this forum on both. Asthma is an obstructive disease, where as CHF is an overload from poor pump syndrome.

Yes, may represent with "wheezes" but the etiology and treatment are not the same. Some studies has shown that administering Albuterol, may actually increase ischemia in CHF patients with Beta [sub:43a7e5dfa7]2[/sub:43a7e5dfa7] properties. Again, since the disease process, is separate ... separate tx.'s Now there is many patients that might have both or better yet have "cardiac asthma which is a totally different disease.

The main point to remember is history, a good thorough assessment as well as using tools such EtCo2 Capnography which will immediate tell if you if they are having obstruction (shark fin waves) versus pulmonary without obstruction & monitor their oxygenation as well with Sp02.

I highly suggest you review each pathophysiology of obstruction airway versus oxygenation perfusion diseases. The rationale for treatment, medications that are utilized will make better sense. Again, these disease are NOT the same and should not be addressed the same way.

Look in the search on this forum, you will find many topics r/t this subject and other web site searches as well.

Good luck,

R/R 911

[Nate]

Yeah, what they said.

[Guest]

First off, firefighter523 if your preceptor yells at you "for any reason".....find a good one and then tell him to give me a call on the mental health hot-line, he's a looser and a poor instructor.

But you have said something here that raises a question with me....2 patients are never the same they may be similar.

Is Albuterol first line treatment for CHF in your protocols?

Now if you can't hear anything on your "silent chest" if you should administer Albuterol, and then develops a wheeze you most likely have strong COPD component, RID is most correct, all that wheezes is not asthma but CHF in acute phazes does have Obstructive and Restrictive components. I personally don't have as much faith in diagnostic ETCO2 as RID, I prefer the stethascope myself.

Good question. In my practice and education I have found this to always bring out an interesting discussion. Even after spending along period of time in a hospital and getting to know a bunch of docs well I have found quite the variance in clinical RX's and opinions on this. I hope what follows here will help your confusion some and clear it all up a bit. Also you can do a search as both rid and I have posted "teaching posts," on CHF.

I am going to be ill, ACE will you never learn that your arrogance is not respected, and it shoots you credibility to hell and a hand basket! there is always controversy in Medicine its the very nature of the beast. All patients are not case book studies, frequently CHF and COPD are one in the same they like to share stuff....the chicken / egg scenario. Its squint not squirm, you think you csan make me squirm....you must be GAY or a girl?

1.) One of the main reasons we don't give a B agonist in an acute presentation of CHF has 2 parts. The literature and evidence backs up these points.

Please provide the studies ACE, don't continue to bombard us all with pages of irrelevant trivial crap PLEASE!

The scenario did not include a tachy rhythm, again you assume, you stated Chronotropy positive I assume?

A.) It increases MIO[sub:a507943987]2[/sub:a507943987] demand through chronotropy. This can cause an infarct, increase the pt's hypoxia, and or worsen an existing infarct-ischemia

B.) It generally isn't a good idea to give a B agonist to a pt who may soon recieve B blockers

Please explain rational and provide documentation to the effect that a "B blocked patient" will not receive any bronchodialatory effects from selective B 2s....hmmmmm good hunting, I have looked!

Question, if patient is B blocked how could the O2 Demand increase with control over tachycardia's....it does not compute!

Now having said this one of the docs who I have had the pleasure of getting to know and has been an ER-intensivist MD for 30 yrs stated to me that he likes to use it in the acute on chronic presentation with little to no possibility or clinical suspicion of MI & in the case where the pt has extremely poor tidal volumes. His ratioanle for this is that the short acting effect of the Albuterol will definately cause an increase in rate and MIO[sub:a507943987]2[/sub:a507943987] demand. Yet it will also Broncho dialate and help improve both the pt's ability to ventialte appropriately ( i.e: TV-Fi0[sub:a507943987]2[/sub:a507943987]), and give you the ability to treat their CHF with the measures you mentioned.

Control Brochspasm therefore improve oygenation, simple. Ischemia leads to infarction....... improve oxygenation therefore decrease "infarct" size, did you say this I must have missed that buried in the mire!

I know doctors blah blah blah it continues to amaze me that knowing an M.D. is a rational justification.

Comparing the YEARS of TIME spent has about as much bearing as pecker comparison.

Now: Just what is an ER intensivst, either a specialist in ER medicine and/or an Intensive Care Medicine.....different letters behind the name may be a hint! is that like sckodocofrenia?

The Albuterol doesn't have a great effect on the terminal airways it works mostly on the larger ones (i.e.: in the bronchus

)

Absolutely incorrect, .2 to 1.0 microns is the optimal size to impact on the target area the "TERMINAL BRONCHIOLES" in administration of nebulised albuterol, Larger particles "rain out' in the Larger airways leading to the Systemic effects of positive chronotropy, please remember the Salbutomol, is Beta 2 selective.

and this these concerns that the pt will flash are usually due to (A & B above) which is a secondary effect of the Albuterol admin. You are merely increasing the potential space for that fluid.

WHAT increase potential space where in the AC membrain?

In 20+ years of practice I've never seen that.

Cause whoever you quoted here is on Crack.

You don't need to worry about that, just becareful and know what your protocols compel you to do"THERE IS A BIG DIFFERENCE BETWEEN USING ALBUTEROL KNOWINGLY IN AN ACTUE CHF PT; VS: USING IT TO DIAGNOSE OR TO DIFFERENTIATE IT FROM ANOTHER DDX, ONE IS OK CLINICAL PRACTICE THE OTHER IS NEGLIGENT AND CAUSES HARM TO YOUR PT

Pulmonary edema, (and some Pneumonia's) affect "J" receptors in the lung.....look that up in your funk and Wankel's ACE!

Here are the links to "RID'S TEACHING THREADS," ON THIS SUBJECT:

I would read Rids myself, Ace just cuts, copy pastes, at infinitum. zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz!

Mark DuFine, M.D; DrMarkJD@aol.com

Mon, 9 Dec 1996 13:33:43 -0500"] As I instruct my medics, it would be a dangerous venture to give

albuterol. You are going to increase the heart rate. This in turn requires

increase in the oxygen demand because of the work the heart is doing. The

patient you are dealing with has a huge O2 demand as it is. Are you

attempting to treat a symptom or the root of the problem?

Lets just say for fun, that no there is no absolutes in medicine, when you hear the sounds of the hoof beats on the ground think horses not zebras.

ACE get down off that hi horse.....its plastic.

Your initial needs in this case is to give the patient supplemental O2,

a diuretic, some preload reducers (Nitro, morphine). You may wish to

consider the possibility of dopamine to help the BP as well as help renal

perfusion

Now this is good advice, but first do a 12 lead please may help a touch.

I would add BIPAP, as a bridge to intubation, as not only is this methodology to match Auto PEEP, improve Oxygenation but overcoming the AC membrane hydrostatic changes associated with Left sided failure but improves pulmonary shunt, improves V/Q match, improving Zone 2 in the lung, by increasing FRC.

It also reduces WOB work of breathing, be aware that the use of PEEP should be monitored like a drug, especially in a borderline b/p problems.

Int J Cardiol. 1984 Mar;5(3):327-38; Potential value of oral beta 2-adrenoceptor agonists in congestive heart failure: a haemodynamic and metabolic study; Timmis AD, Bergman G, Walker L, Monaghan MJ, Jewitt DE. wrote:

KEY WORD HERE IS "ORAL" read all the words, ACE you should head my Fathers advice.

OH I fell SO much better, no wonder I was sick I had vomit in my belly.

TAG ACE your IT, no doubt in my mind at all, but no signs please thats so high school.

[Ace844]

First off' date=' firefighter523 if your preceptor [b']yells at you "for any reason".....find a good one and then tell him to give me a call on the mental health hot-line, he's a looser and a poor instructor.

But you have said something here that raises a question with me....2 patients are never the same they may be similar.

Is Albuterol first line treatment for CHF in your protocols?

Now if you can't hear anything on your "silent chest" if you should administer Albuterol, and then develops a wheeze you most likely have strong COPD component, RID is most correct, all that wheezes is not asthma but CHF in acute phazes does have Obstructive and Restrictive components. I personally don't have as much faith in diagnostic ETCO2 as RID, I prefer the stethascope myself.

[firefighter523]

I didn't mean to start a war. Under my impression from the people that I have learned from, if you can't hear anything because a pt's tidal volume is very low, then you should administer albuterol to increase tidal volume for two reasons, 1) So they can breath, and 2) so, when they are able to take in a full breath, so you can hear whatever it is you hear. It seems to me that this issue is very controversial. This lady presented in bed, in a nursing home, on 2lpm 02 via NC. I listened to her lungs and heard clear lungs. She was breathing 32 times a minute with a pulse ox of 78%. She had a documented history of CHF in her chart, and she was ashen in color, and cold. It is my understanding that you can be in failure, and not be congested. We took this lady into an ED with a history of CHF, pale skin, breathing 32 times a minute, with a pulse ox of 80% on 15lpm 02 via NRB. The PO never increased above 80. Because she was so tachypneic, and she had a history of CHF, and she was ashen in color, I would have given her an albuterol tx to open her up, then with the nitro, lasix, CPAP.

When we got to the ED, the firt thing they did was put her on BiPap!! The idiots I ran with blamed the pulse ox not functioning right, because of cold skin. I was embarassed to go into the ED. I know I have ALOT to learn, but I think I am on my way of recognizing HF. She was brought in just on 02. Not acceptable!! Sorry, I'm venting

[Guest]

I didn't mean to start a war.

First and foremost, excellent post:

No war just a friendly exchange of ideas man those that become personal are losers through lack of credibility, they make themselves look so foolish, they assume and read into things....... you sir have not, your conundrum is very valid.

Under my impression from the people that I have learned from. If you can't hear anything because a pt's tidal volume is very low, then you should administer albuterol to increase tidal volume for two reasons, 1) So they can breath, and 2) so, when they are able to take in a full breath, so you can hear whatever it is you hear.

Most excellent, you have been taught well, to breath is to bee.

It seems to me that this issue is very controversial.

Medicine always is, thing is challenge of the old ways/ideas is the way we learn, and improve, you are well on your way.

This lady presented in bed, in a nursing home, on 2lpm 02 via NC. I listened to her lungs and heard clear lungs. She was breathing 32 times a minute with a pulse ox of 78%. She had a documented history of CHF in her chart, and she was ashen in color, and cold. It is my understanding that you can be in failure, and not be congested. We took this lady into an ED with a history of CHF, pale skin, breathing 32 times a minute, with a pulse ox of 80% on 15lpm 02 via NRB. The PO never increased above 80. Because she was so tachypneic, and she had a history of CHF, and she was ashen in color, I would have given her an albuterol tx to open her up, then with the nitro, lasix, CPAP.

I totally agree, but with nitrates watch B/P and a R sided infarct, do you think your looking at a shocky patient here? and why? what would be a plausible plan of action reviewing all of the preceding advice?

Think it through friend!

When we got to the ED, the first thing they did was put her on BiPap!! The idiots I ran with blamed the pulse ox not functioning right, because of cold skin. I was embarrassed to go into the ED. I know I have ALOT to learn, but I think I am on my way of recognizing HF. She was brought in just on 02. Not acceptable!!

BI PAP thats a capital idea I wish I had thought of that LMAO.......

OK which idiots......ER/ICU Intensivists or EMS........its a virus me thinks?

True though, decreased perfusion can give erroneous readings...with pulse ox, shes breathing at 32 bpm yes? Did you see ABGs?

Sorry, I'm venting

You Vent brother man...... that's why we are here Dude, we have all been there.

Do you think ACE is doing any less he just has not come to grips with that yet he has much to learn as a teacher.

At least you know you are have no airs of false grandeur.

You Sir, are far more concise, succinct, you can treat me any-day...!

[firefighter523]

Thank you my friend, I am learning from some good medics, others in my opinion have not impressed me. But I am still learning.... By the way you would have gotten a 12 lead first, if you had elevation in 2, 3 and AVF, and RV4 it would have been a balancing act, not to do fluid overload, but to maintain that left ventricle feed!! Thanks for your advise, and I didn't see ABG's.

[Guest]

Thank you my friend, I am learning from some good medics, others in my opinion have not impressed me. But I am still learning.... By the way you would have gotten a 12 lead first, if you had elevation in 2, 3 and AVF, and RV4 it would have been a balancing act, not to do fluid overload, but to maintain that left ventricle feed!! Thanks for your advise, and I didn't see ABG's.

CAPITAL!

Get the ABGs next time or I will have to kill you!

LMFAO

squint not squirm.