Giving Albuterol to decrease potassium.

Lately we at my humble hospital have been getting more and more orders for albuterol nebulizer treatments to decrease a elevated potassium level in a patient. This has made me curious as to why this works and if it really is a viable reason to give albuterol and a elevated potassium situation so I did some digging and here are some facts I found:

- Potassium is both an electrolyt and a mineral. It helps keep the water and electrolyte balance of the body. Potassium is also important in how nerves and muscles work.

- The normal level of potassium is 3.5-5.0 mEq/L

- Albuterol works to create smooth muscle relaxation through the beta-2 receptor site but one of it's other effects, is to reduce extracellular potassium concentrations by pushing the potassium into the cells. This action is quite handy, in a pinch, but do not rely on it because the action is too slow in it's onset to be of emergent help.

- Doses of 15 mg albuterol via nebulizer, hyperkalemic patients on hemodialysis experienced a 0.9 mEq/L decrease in plasma potassium which was sustained for 6 hours. Albuterol may stimulate sodium-potassium ATPase, resulting in an intracellular shift of potassium.

- Albuterol works to lower potassium concentrations by stimulating the release of insulin. This release of insulin shifts the potassium into the cells thus lowering the potassium level.

- Albuterol also stimulates the Na/k+ pump causing potassium to be shifted into the cells.

- A study compared the efficacy of 1) insulin + glucose. 2) albuterol and 3) both regimens combined when used to lower potassium concentrations. The study found that albuterol was just as effective and quick at lowering potassium concentration as insulin + glucose. The study also found that the two treatments administered together worked even better in reducing potassium level. Albuterol reduced the potassium level by up to almost 1mEq (0.62 - 0.98mEq).

Source: http://www.ncbi.nlm.nih.gov/pubmed/2266671

- Using a large amount of albuterol in a patent not in hyperkalemia may cause the patient to become hypokalemic.

- The dose for albuterol when administered in hyperkalemia is 10-20mg.

- It is mentioned in ACLS for Experienced Providers (2003) p.162.

• For moderate elevation of potassium (6 to 7 mEq/L):
  
• Initiate a temporary intracellular shift of potassium using the following agents:
  
• * Sodium bicarbonate: 50 mEq IV or up to 1 mEq/kg over 5 minutes
  
• * Glucose/insulin: Mix 10 U regular insulin and 25 g (50 mL of D50) glucose, and give IV over 10 to 15 minutes
  
• * Nebulized Albuterol: 5 to 20 mg over 15 min.
  

Well after doing some research on the subject to me it does look like a viable treatment to assist in the treatment of Hyperkalemia in patients, but from what I have been noticing is that the Doctors are not ordering this properly to even make a dent. We here at my hospital get orders for just a regular nebulized albuterol treatment of 2.5mg which is nowhere near the recommended 10-20mg to even cause a dent in the potassium levels.

To be curious about why your doing something is a good thing and the internet is a plethera of information to be found in our profession. If you have questions, research it.

Keep driving on RT's.

Nebulizers or MDI's inline with a Ventilator?

Here at my hospital we seem to go through streaks of how we give medication to patients on ventilators. For a couple of months we might use MDI's and then we might just switch over to Nebulizers inline for a couple of months, and it is normally the same doctor who will oversee these patients on vents, it would be our pulmonologist who does it.

Tonight I just came back from being off for 2 days and we now have 3 ventilators running and all three of them are getting nebulized medications. One of the vent patients used to be getting MDI treatments but has now been switched over to nebulizer treatments. So I got to thinking which is better? Could this just be because he has Xopenex ordered as one of the medications along with Atrovent? Shouldn't be the reason we carry these by MDI also I have heard, even though I have yet to see a Xopenex MDI here at this hospital.

Doing some reading online and my own personal experience I have found different pro's and con's of using either a nebulizer or MDI with a ventilated patient, this is what I'm going to try and share with everyone, and I am looking forward to any opinions you might have for either side.


Metered Dose Inhalers Inline with a Ventilator

• MDI's have to be perfectly timed with a vent cycle
• MDI's give better deposition
• You need more puffs from the MDI to get a regular dose to a patient due to the moisture in the ETT that will cause the medication to stick to the ETT or inspiratory limb of the vent circuit. I have seen anywhere from 4 to 24 puffs given at any one time.
• MDI's treatments are faster than nebs.
  
• Need to give a pause after the breath otherwise the majority of the medication could possible go out the exhalation limb.
• You have to push the MDI right after the inhalation cycle starts or if your to early a lot of the medication goes out the exhalation side, you can actually watch this.
  

Nebulized medications Inline with a Ventilator

• Becomes a vapor like the humidification
• Do Not have to time with the ventilation cycle
• Same dose as you would use with a non ventilated patient
• Does take longer
• Does increase measured exhaled tidal volume and minute volume
• decreases the trigger sensitivity of the pressure supported breaths due to higher flow making a bigger negative pressure necessary, increasing he work of breathing in the patient
• may cause problems with the internal ventilator components due to the medication sticking to the components
• should possibly use a extra expiratory filter and maybe a inspiratory filter to protect the ventilator

Those are just some quick little notes of interest I have come across in my researching information for this article along with information I have learned as my time of being a RT.

Some more information I have learned about the placement of the nebulizer and MDI's when you give the treatments I have found and some I have known or used in the past.

When giving a MDI through a ventilator you should put the MDI inline as close to the wye as possible and up to 6 inches behind the wye. Always give the puff timed with a inhalation cycle or it will go down the exhalation side and not to the patient.

With the nebulizer inline I was really curious about the best way to place the nebulizer inline as to get the best treatment and from what I found which was the consensus was to put the nebulizer as far back from the wye on the inspiratory side as possible. Some even will put it behind the humidifier as they found that the aerosol of the nebulizer will mix with the humidified water aerosol, which are basically both the same. The reason it is said to place it farther back is so the inspiratory limb on exhalation will fill up with the nebulized medication aerosol and on inhalation there is a larger concentration of medication given to the patient. There is also the old law that says a gas will go towards the area with the least resistance, so if its closer to the wye the exhalation flow will be the area of least resistance due to the flow and there is a entrainment aspect to that side of the tubing also. Which makes sense to me.

I now after reading am more partial towards the use of nebulizers inline with a vent than MDI's at this time. I also will be moving my nebulizers farther back from the wye, which I will do here in about a hour's time. I lot of my questions were answered by doing some research and I hope I might of given you some more information that you never really knew.

One more thing, DON'T Forget to remove the HME before you give a treatment!!!

Drive on RT's

I always thought is was A.B.C.

One basic principle that was driven home to me as a medical professional in either of my schools, be it my Combat Medic course, EMT course or Respiratory Therapist course has been the concept of the ABC's, also known as Airway, Breathing, Circulation. This has always been understood my be to be there order of importance when it comes to a person in medical need. Yes this is supposedly for mainly first responders and emergency situations.

Now in the Emergency Room I would think that this would come into play, because well its a emergency room. Unfortunately I have noticed at many places, and a lot where I work that I will get a call the the ER for a patient that needs a breathing treatment. This usually tells me that there is a person in the ER that is having some type of difficulty breathing, and if you look at the ABC though process it would be number 2 on the list, because if they can breath in a nebulizer tx the airway must be somewhat patent.

Here is my issue that I see more and more, I'm called to do a neb in the ER and when I get there I will get from the nurse and sometimes the doctor, "Oh I'm sorry Xray got here before you so they took the patient to get their Xray done." Or there will be Xray there and they just do the "Haha I beat you here" thing. Sometimes I even get the, "Can you give us a minute, we need to put in this foley catheter first." Then comes the "Hey come do this EKG first before you do the neb treatment."

Does anyone else see anything wrong with these scenarios? As far as I know I would think that breathing would take precedence over Xrays, plus you would get a better view of the chest with a more open chest I would think, but then I'm not a Xray person. I would also think that breathing would be a little more important than a foley catheter, but a foley catheter could help with the breathing if they are fluid overload, so lets both do our thing at the same time. And that EKG before giving this neb to a asthmatic, look at your ABC's, circulation comes after breathing.

There are many times a patient doesn't really need a neb very badly and it's not a emergency situation, but even then it's irritation to be called away from what you were doing to show up and the patient was gone to Xray. Maybe this is more of myself complaining about something, but it irritates me to think that when it comes to patients feeling better, an xray will make them feel better than the nebulizer that will ease their breathing. Personally I would rather be breathing better than getting a picture taken.

Thanks for reading

Drive on RT's

You Heard What?

A patient comes into the ER the other night with complaint of chest pain so I'm called down to do a EKG on the 35 year old with chest pain. I get into the room start to do the EKG and she becomes very shy about me putting on leads. Every lead I put on she quickly pulls up her gown and the lead falls off. "Sorry ma'am I have to get this back on could you please wait until we have the EKG done, I will go as fast as possible." So I finally finish and EKG is showing normal sinus rhythm and she going into this excruciating pain look and perfectly complaining "Owwww it's hurting right over my heart and very heavy right now with the pain going to my jaw and radiating down my arm." So I give the EKG to the Doc and she say this person has been here like 20 times in the last week, she is a nut case. Great so off I go.

35 Minutes later I'm called to come down and do a nebulizer treatment in the ER and when I get there the Doc tells me it's in the same room as the nut case. I ask "Is she short of breath, she didn't seem short when I was in there and didn't complain of that?" Now here is the response I received from the great and powerful doctor, "She is having a slight wheeze with a forceful exhalation, so maybe she has a little asthma component with exertion." Okay key phrase here if you didn't notice it, "With a FORCEFUL exhalation...".

Damn right she does with a FORCEFUL exhalation, so do I watch.....wheeeeezzzzeeeeee....See I can do it also and I have no breathing problems what so ever, and I'm sure you can do it to. The Doc actually told her to breath out as hard as she could, what the *&^%!!!

Well so I didn't actually say all that to the Doc. But I took a peak flow meter in the room with me to check the patient, we use the low flow ones in the ER (don't ask why) but it only goes up to 375. I give the PF to the patient and she all about blows the room off the room with that thing, plus her lungs are clear as a bell. Off I go and let the doctor know my observations and she is stunned and says "Wow maybe I just heard something at the right time, I guess her lungs are good, but lets give the neb anyways because I might soothe the patient a bit." Alright whatever again the nebulizer works as a pacifier.

After the nebulizer the doc then tells me that she is indeed a nut case and a attention seeker and it's thought that she does a bit of research so she can use the correct symptoms of the problem she is seeking help for. Ya have to love these types of patient and how they can just take up your time and run you schedule right into the ground.

Oh well all is life in your friendly community hospital. I work in a small town hospital now instead of the big city one I used to and when you compare the to there is a difference but in a small town one it seems there are a lot of bored people, namely elderly, who just want some attention so they go to the ER. Job security is the way to look at it.

Until next time, don't inhale chasing it with a exhale.

Desaturating while giving a Neb Tx. What to do?

There are times when a patient is on a large amount of O2 and a nebulizer tx has to be given, but we know that a standard neb given with only 6-8 lpm is not enough flow or fio2 to keep O2 saturation >= 90% (our current protocol), so what do you do?

Drawing on my personal experience and reading about other RT's idea's and experience here are some ways to help keep the patients saturation at appropriate levels or at least close appropriate.

1. Place a nasal cannula under the aerosol mask or run with a standard HHN.
2. Place 6 inch large bore tubing in the holes in the aerosol mask, looks like elephant tusks.
3. Tee in the nebulizer into a non-rebreather mask. This gives the highest fio2 in my opinion.
4. With a regular HHN instead of using a 6 inch reservoir tube on the end, increase the length of the reservoir tube to 3 lengths of 6 inch tubing or whatever you think will work, this will decrease the amount of room air that patient with entrain.
5. You could always just put the HHN under the Non Rebreather mask but this can also cause comfort issues for the patient in my opinion.
6. If they just need a little extra fio2 you can always use a HHN with nose clips, this way it decreases the amount of inspired Room Air through the nose.
7. Place the HHN in the side port of the aerosol mask and run oxygen from the normal port of the aerosol mask.

Alright there are a few different ways to increase fio2 while running a neb and I'm sure there are many other rigged ways I would like to hear about, but you must also think, is the flow of the extra oxygen going to hinder the deliverance of the medication of the neb or not? I guess if this situation comes up see what works and go for it.

If anyone has any other ideas of ways to complete this task feel free to post a comment or criticism on the ideas I have posted here. Thanks for reading and responding.