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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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.
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.
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.
The CHF/COPD/pneumonia diagnosis is one of the most difficult to make. These patients require more critical thinking than almost any other, and poor decisions can do real damage. My philosophy is that the further down the protocol you get, the risk goes up and the potential benefit goes down. CPAP and nitro are very good for CHF. If used on a normo/hypertensive pneumonia patient, nitro won't do that much damage. Lasix can be harmful, and there's less potential benefit from giving it in the field vs. a few hours later in the hospital after an X-ray. I generally don't give Lasix unless a patient's BP is over 180 (not based on evidence, just my experience).

I also think that CPAP lowers the risk of albuterol flooding CHF patients. I'm much less hesitant to try albuterol on borderline wheezing patients if it's being delivered through CPAP.
One thing that's missing from this thread is the mention that most CHF patients are not hypervolemic. That used to be the justification for use of Lasix: a pt with a bunch of fluid in his lungs obviously needs to have fluid taken off. But since we've gradually discovered that this isn't true--most CHF pts are euvolemic (and occasionally hypovolemic), even if you ignore the risk of misdiagnosis there's no reason to dehydrate everyone indiscriminately.
That's what I referenced when talking about our (I say our, you're from Pitts, right?) current state protocols, that we only use it when there's history of CHF and they're already on a diruetic, as opposed to a new, undiagnosed condition.

dr-exmedic said:
One thing that's missing from this thread is the mention that most CHF patients are not hypervolemic. That used to be the justification for use of Lasix: a pt with a bunch of fluid in his lungs obviously needs to have fluid taken off. But since we've gradually discovered that this isn't true--most CHF pts are euvolemic (and occasionally hypovolemic), even if you ignore the risk of misdiagnosis there's no reason to dehydrate everyone indiscriminately.
But why give it when NTG reduces the preload, takes them out of APE, relieves the shortness of breath, and raises the SpO2? What's the rush?

Tom

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