Can anyone answer whether albuterol helps or hurts patients in CHF? I get this question a lot teaching, and am not sure what the anwer is. I've heard different theories about albuterol opening alveoli. which causes them to flood in CHF patients. Does anyone know if this is true, or where I can find some literature about this? Thanks.

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Im just asking that question because the last service I worked for had very open orders and the only thing we really had to call for was lasix. The medical director's reasoning was because a medic gave it to a pneumonia patient one time. I was confused as to why this would be such a big deal so I asked a few Drs at the large hospital where I also worked part time and they didnt understand the high level of concern either. If you give lasix to someone who turns out to have bi lat pneumonia and a chest X-ray a short while later at the hospital shows pneumonia then you simply open the IV up a little more...............

"More importantly for us in the UK it would be a case of giving a drug off licence and outside of prescription rights. You would lose your registration quicker that you could google a defence."
Well that sounds a bit harsh!
It is harsh, but i suppose its the price you pay for being an autonomous practitioner. Which is why in probably most medical calls, some if not many paramedics in the UK will adopt a wait and see approach unless it is textbook obvious what is going on, "preservation of ABC's and let the Dr worry about the diagnosis".

It comes from the feeling that instead of protocols or standing orders we have guidelines... which the paramedic uses as a base of knowledge to guide his practice is the theory anyway. on the other hand, you would need to either be very good clinically or have a hole in your head to step wildly outside them...(meaning if you make a mistake you can't hide behind, "well i did what it said here, sir" but use it to make and informed evidence based argument for your decision)

Coupled with the fact that it was recently established that only 10% of 999 calls are true ambulance/paramedic emergencies (where a paramedic/ambulance skill is required) outside of supportive care and transport to hospital. You could therefore argue a lack of contact with acute CHF goes partly to explain the wait and see approach.

I've been at this around 3 years now and I have seen 2 patients that presented as textbook CHF and responded impressively to nitrates, many times it is a balance of probability, and we get called to nursing/care homes, and helpful GP's listen to the care staff "well he sounds a bit chesty" and the GP prescribes antibiotics over the phone....several hours later when the pt is near death an ambulance gets called and there are enough red flags to go either way in these cases...

I suppose the question is, does the lasix harm the pneumonia pt? My search on this here Mac Papers thingy seems to suggest so...Does that then mean that further and advanced pt assessment skills are required in order for the safe tx of CHF? or will the evidence inform practice and leave lasix behind in favour of nitrates and CPAP?

I'm not too sure on the whole "open the IV up a little more", Does it breed a culture of firing blindly in to the night with treatments on the basis that the ER can reverse/correct it??? Rather than paramedics thoroughly assessing patients and devising a sound evidence based treatment plan....

Nathan said:
"More importantly for us in the UK it would be a case of giving a drug off licence and outside of prescription rights. You would lose your registration quicker that you could google a defence."
Well that sounds a bit harsh!
I've heard about albuterol increasing someone's heart rate, but have never seen a patient's heart rate increase that much with it. Lasix for pneumonia is bad. If a patient is hypertensive and already takes Lasix, it is not as bad. Dehydration and fever are the company that pneumonia keeps, and this is one area we can do real damage to someone.
I agree that a pneumonia pt given diuretics is bad if its not recognized within a short amount of time. I agree that most of the time if we aren't sure the patient needs lasix they can easily wait to get it untill some other tests are done to confirm. But what Im getting at is; do we really hurt much if we misdiagnose a patient with CHF and barring all other contraindications for loop diuretics give them lasix? (assuming that shortly thereafter the chest Xray shows pneumonia and the patient is given fluids to make up for it)
The patient loses more than just water, but electrolytes. Dehydration could be bad enough, but an electrolyte imbalance could prove worse and can be more difficult to correct. Considering that pneumonia patients may already be dehydrated and potentially septic, lasix would just put them that much further behind in treatment as the first few liters would be dedicated to getting them to where they were (fluid wise) prior to lasix.
Scott,

I'm with you on avoiding Lasix for patients who may have pneumonia...

In addition to thickening mucous plugs (bad) and intentionally deyhdrating a patient with an infection (bad) I'm thinking that paramedic-induced hypokalemia probably isn't good for the patient, either.
Ya that makes sense. I didnt really consider how much it could effect the electrolytes. Im not sure that a little bit of lasix would effect them enough cause dire consequences but I see what your saying. Good stuff.

"considering that pneumonia patients may already be dehydrated and potentially septic,"
Thats where the no other contraindications part comes into play. We should quickly recognize sepsis. Im talking about the patients in the grey area.
If they're pneumonia is the primary cause of the respiratory distress, and they're already dehydrated from the increased metabolic demands, hyperthermia, decreased intake, etc., then someone comes along and, thinking the problem is exacerbation of CHF, and gives them a diuretic, they have just contributed to the dehydration, and may push that person over the brim to hypovolemia. That would go double if the pt. is in septic shock, or close to it.

BR>Just curious, whats really so bad about giving someone lasix when it turns out they have bi lat Pneumonia?
I have seen what albuterol does to a chf'er.. it opens them up and floods them.. I got caught with the history of both chf and copd. She was weezing, started her ona combi-treatment. Within 2 minutes, she was flooded to the point that she has no breath sounds. Why complicate an already complicated problem..
If you cannot tell the difference between copd and chf, the patient has both, work it from both ends- nitrates and diuretics for the failure and dialators for the copd.. This would be the only time.
Basically, it dries them out when what they need is fluid to thin out those gunky secretions. In a worst-case scenario, which I have seen, it can lead to death.

Nathan said:
"whats really so bad about giving someone lasix when it turns out they have bi lat Pneumonia?
As a side note to this, I am allergic to albuterol, so I always administer it via NRB. This gets more of the stuff to the patient and less to me.

Tom Bouthillet said:
On the rare occasion that I give albuterol, I use both oxygen trees and place the patient on a NC @ 4 LPM along with the handheld nebulizer, since a tired CHFer spends a lot of time with the inhaler away from the face. My service is late into the CPAP game (we're implementing it in the next 30 days) but it seems to me that NTG and CPAP is the way to go. It should also go without saying that new onset pumonary edema should be treated as a possible ACS until proven otherwise.

Tom
The beneficial vasodilation seen initially upon administration of Lasix is occasionally offset by subsequent vasoconstriction. Also, a study from the '90s (I can't remember the exact year) showed, of NTG, Lasix and MS, NTG was by far the most effective prehospital med for tx of APE.

I still find medics and nurses who identify NTG with "chest pain" only, and think of Lasix as the first-line tx for CHF. This thread has referenced several good reasons not to respond that way.

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