Xopenex in place of Albuterol for Suspected Cardiac Wheeze

[AeroClinician]

Is there any agency out there that has a protocol for xopenex in place of albuterol for a suspected cardiac wheeze?

 

[DrankTheKoolaid]

No as cardiac asthma is not an indication for a beta adrenergic that will potentially worsen the patients condition by further increasing the work of the heart. Ntg and cpap is what they need and the wheeze will correct itself

 

[AeroClinician]

No as cardiac asthma is not an indication for a beta adrenergic that will potentially worsen the patients condition by further increasing the work of the heart. Ntg and cpap is what they need and the wheeze will correct itself

Here is the problem with treating a suspected cardiac wheeze immediately with nitro, cpap and possib. lasix -> Its because if you are wrong and it is not a cardiac wheeze, then you will dry out your patient and the condition will get worse. Because we cannot determine for sure it is a cardiac wheeze or non cardiac wheeze we must give a bronchodialator as a diagnostic tool first to confirm our suspections then switch off to CHF treatment for the confirmed cardiac wheeze. A good example is a patient that has Asthma and CHF presenting with wheezes. And it comes down to giving xopenex instead of albuterol because xopenex has less B1 effect with a good B2 effect.

 

[usalsfyre]

Here is the problem with treating a suspected cardiac wheeze immediately with nitro, cpap and possib. lasix -> Its because if you are wrong and it is not a cardiac wheeze, then you will dry out your patient and the condition will get worse. Because we cannot determine for sure it is a cardiac wheeze or non cardiac wheeze we must give a bronchodialator as a diagnostic tool first to confirm our suspections then switch off to CHF treatment for the confirmed cardiac wheeze. A good example is a patient that has Asthma and CHF presenting with wheezes. And it comes down to giving xopenex instead of albuterol because xopenex has less B1 effect with a good B2 effect.

Leave out the lasix and it's not really "drying out" a patient. Levalbuterol's price makes it an unrealistic choice for most of EM, let alone EMS. Finally, good history will usually narrow down your root cause.

 

[AeroClinician]

Leave out the lasix and it's not really "drying out" a patient. Levalbuterol's price makes it an unrealistic choice for most of EM, let alone EMS. Finally, good history will usually narrow down your root cause.

But if price is not an issue because it is only on the truck for this single purpose then it really couldnt be that expensive to carry 1 dose per unit. I know what your talking about with looking for a history of sudden onset (cardiac wheeze) vs a slower onset (Non-cardiac wheeze). The problem is that some medics cannot be trusted to adequately decipher cardiac vs non-cardiac and they end up giving nitro to the non-cardiac wheeze and the patient ends up dying because the pt.s condition was so bad to begin with.

 

[Sublime]

Is training your paramedics to differentiate acute asthma attacks from CHF exacerbation too much to ask?

 

[AeroClinician]

Is training your paramedics to differentiate acute asthma attacks from CHF exacerbation too much to ask?

Its just too easy to be wrong in this situation and it is much better to use xopenex as a diagnostic tool first to confirm suspicions.

 

[NYMedic828]

Here is the problem with treating a suspected cardiac wheeze immediately with nitro, cpap and possib. lasix -> Its because if you are wrong and it is not a cardiac wheeze, then you will dry out your patient and the condition will get worse. Because we cannot determine for sure it is a cardiac wheeze or non cardiac wheeze we must give a bronchodialator as a diagnostic tool first to confirm our suspections then switch off to CHF treatment for the confirmed cardiac wheeze. A good example is a patient that has Asthma and CHF presenting with wheezes. And it comes down to giving xopenex instead of albuterol because xopenex has less B1 effect with a good B2 effect.

Really...

First off if someone is suffering an asthma attack, while it is rather unpleasant for them, it isn't necessarily an immediately life threatening condition. Most patient's asthma won't progress, at least not that rapidly, to a state of respiratory failure. It isn't a condition we need to treat immediately unless the signs of respiratory failure are presenting. A full assessment should be done prior to any treatment.

Asthma is an inflammatory process with an increased mucus production actually making the bronchi "wetter" than dryer. Mucus is a combination of the secretion mucin, and water. Administering that beta agonist if anything causes the lungs to dry out more than remain moist. Especially if you administer atrovent.

Now, if you suspect someone of multiple pathologies or their history suggests it, it is even more reason to do a full assessment. Good lung sounds will tell you a lot about a patients condition and it couldn't be simpler to assess. Granted some patient's are difficult to auscultate more often than not its pretty easy if you keep the environmental noise to a minimum. Heart sounds could also be a good indicator of cardiac failure if you are competent enough to pick up a murmur that could suggest prolapse or regurgitation.

An ECG should always be performed prior to administering medication to a suspected CHF exacerbation. It may be an acute exacerbation of a chronic condition, it may be an acute episode of more substantial heart failure like an MI that can be detected via ECG.

If we decide the patient is suffering from CHF, NTG and CPAP are the current gold standard out of hospital. Anxiolytic if necessary to minimize the sympathetic response if your system permits it in some cases. Lasix is no longer considered a very viable treatment in acute exacerbation of CHF because the sympathetic response reduces renal blood flow making the effect of lasix very sparatic and often ineffective until the exacerbation is mostly resolved. It doesn't work to well if the kidneys are being disregarded. On top of that, CHF patients are often euvolemic or even hypovolemic. Rarely are they truly hypervolemic needing diuresis.

Quite often patients with COPD or asthma do have CHF and can very well be experiencing both problems but I would treat the CHF before I would treat the asthma every time. I would rather not make the heart work harder if it isn't completely necessary to proper care of the patient.

Its just too easy to be wrong in this situation and it is much better to use xopenex as a diagnostic tool first to confirm suspicions.

It is wrong to administer unwarranted medications that have the potential to result in adverse reactions that the patient can't tolerate.

 

[Sublime]

Its just too easy to be wrong in this situation and it is much better to use xopenex as a diagnostic tool first to confirm suspicions.

I'm going to have to respectfully disagree. If your able to obtain a decent history and look for clues outside of just listening for wheezing I think you can make a pretty good clinical decision on whether or not to give nitro.

And I didn't know it was still the standard to give Lasix in CHF patients, especially pre-hospital. Most places I know have moved away from that and stick to ACE Inhibitors / Nitro / CPAP

 

[MSDeltaFlt]

Is there any agency out there that has a protocol for xopenex in place of albuterol for a suspected cardiac wheeze?

Absolutely not and I'll explain why. Suspected "cardiac wheeze" is still Congestive Heart Failure with the operative word being Failure. So why would you give a beta agonist (which stimulates the myocardium) to a heart that is already failing?

"Cardiac Wheeze" is not musical. It's coarse; marked coarse to fine coarse, but still coarse. That says fluid/edema: oxygen, nitrates (if VS/12-leads allow), and CPAP. Auscultated bronchospasm is usually musical (not always I know), that in and of itself says "spasm" which screams "give bronchodilation".

Nebulized medications in the presence of fluid does precisely @#$% in achieving your patient care goals.

 

[FLdoc2011]

And I didn't know it was still the standard to give Lasix in CHF patients, especially pre-hospital. Most places I know have moved away from that and stick to ACE Inhibitors / Nitro / CPAP

Diuretics are still Grade 1B for acute decompensated heart failure from what I see and certainly still what our groups are doing.

In regards to the original topic I agree, a good history and exam should tell you which direction you're going to go with the patient. Honestly, on the inpatient side we rarely use xopenex. I just don't think the evidence for it over albuterol is that good, and anecdotally I just don't see much difference clinically to justify using it much. Exceptions may be if they had bad reaction to albuterol or they already took a dozen treatments at home before arriving and are now cruising along at 130 bpm or something. Even in most cardiac pts (hx CHF, afib, etc...) I see albuterol tolerated well.

 

[FLdoc2011]

http://www.ncbi.nlm.nih.gov/pubmed/18572345

J Emerg Med. 2011 Feb;40(2):135-45. Epub 2008 Jun 24.

Should acute treatment with inhaled beta agonists be withheld from patients with dyspnea who may have heart failure?

Maak CA, Tabas JA, McClintock DE.
Source
Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA.

 

[RocketMedic]

Is there any agency out there that has a protocol for xopenex in place of albuterol for a suspected cardiac wheeze?

At EMSA, we can substitute prescribed xopenex for abuterol if the patient has a supply handy.

 

[NomadicMedic]

Doesn't anyone else use end tidal caponography as a diagnostic tool? Asthma/COPD and CHF have very different looking wave forms.

 

[RocketMedic]

Doesn't anyone else use end tidal caponography as a diagnostic tool? Asthma/COPD and CHF have very different looking wave forms.

*Raises hand

 

[MSDeltaFlt]

Doesn't anyone else use end tidal caponography as a diagnostic tool? Asthma/COPD and CHF have very different looking wave forms.

I do.

 

[DrankTheKoolaid]

Firehazmedic, go listen to EMcrit talk on SCAPE its like episode 1 or 2. It will make our answers make sense

 

[Sublime]

Diuretics are still Grade 1B for acute decompensated heart failure from what I see and certainly still what our groups are doing.

Perhaps I worded it wrong. I know it is still the standard in many hospitals, but from what I understand physicians are slowly moving away from Lasix for emergent treatment of the unstable CHF patient. It certainly is in the pre-hospital side, I know we don't even carry Lasix anymore. We give Nitro / Captopril or Morphine / Enalaprilat along with CPAP.

http://http://roguemedic.com/2012/06/chf-treatment-is-furosemide-on-the-way-out/

Also a direct quote from Dr. Scott Weingart of EMCRit when asked when to start diuresing SCAPE (Sympathetic Crashing Acute Pulmonary Edema) patients.

When they are comfortable and the blood pressure is where you want, observe intravascular status. Then consider fixing it, usually the answer is they need fluid, not diuresis

EDIT: Here is a link to the podcast for the OP. http://emcrit.org/podcasts/scape/

 

[AnthonyM83]

No as cardiac asthma is not an indication for a beta adrenergic that will potentially worsen the patients condition by further increasing the work of the heart.

There's some strong statements on here about using albuterol on CHF patients. Yet, ER doctors routinely give it and are okay with giving providers giving it prehospital.

Wasn't there a discussion about this awhile ago discussing benefits of opening up the airway that might be reactive to the lung fluid. The idea that it might not fix the cause, but help alleviate a symptom.

I'm not telling someone to do it one way or another, but consider that there ARE different acceptable ideas regarding this topic...

 

[325Medic]

Doesn't anyone else use end tidal caponography as a diagnostic tool? Asthma/COPD and CHF have very different looking wave forms.

I do also.

325.