Moderator EMEDPA Posted July 29, 2015 Moderator Share Posted July 29, 2015 anyone do this? I have a pt who swears it is the only thing that works for her. I did some research that says it isn't better than placebo. will probably try it once for my n=1 study. 3 cc lido 2% + 3 cc ns nebulized x 1. will see what happens...she already got a bunch of albuterol and steroids from the medics. failing that, will try my fallback of low dose ketamine. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted July 29, 2015 Share Posted July 29, 2015 Out of curiosity do you ever switch to levalbuterol if albuterol isn't cutting it? Years ago when Xopenex was the next great thing we'd alternate and occasional get better results (peds EM doc really liked it). Vice versa also seemed to work on occasion. I've rethought the process over time and if the pt has "wet" wheezing (loose cough)/SOB I'd always throw in the ipratropium to dry them up at the same time. Sent from my iPad using Tapatalk Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 29, 2015 Author Moderator Share Posted July 29, 2015 I almost always use duonebs, especially on the copd folks. the other trick an RT showed me recently was using heliox along with the meds instead of room air or o2. my favorite so far is duoneb on heliox through bipap circuit + ketamine 0.1 mg/kg iv to relax skeletal smooth muscle in the chest wall. Link to comment Share on other sites More sharing options...
Moderator ventana Posted July 29, 2015 Moderator Share Posted July 29, 2015 I think my hospital would freek if a measly PA ordered ketamine..... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 30, 2015 Author Moderator Share Posted July 30, 2015 ketamine is much safer than almost any other option for procedural sedation. when I was a student at a peds ed in the early 90s we would give kids IM ketamine 4mg/kg and do our procedures with no monitoring of any kind and no RT or RN in the room with the provider. I did a procedural sedation for a lip lac in Haiti, handed the kid back to the dad when done, had him sit in the corner and said "when she wakes up you can go home". Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted July 30, 2015 Share Posted July 30, 2015 I can remember our hospital anesthesiology department having a cow when our ED director wanted to use ketamine for kids lacerations in the early 90's. My how times have changed. Sent from my iPad using Tapatalk Link to comment Share on other sites More sharing options...
sk732 Posted July 30, 2015 Share Posted July 30, 2015 I love ketamine with kids...never heard of it used in asthma, though it makes sense intuitively and will certainly take away that breathing stress. Knowing the folks I work with the way I do, you have any articles regarding that? Being a bit old, I sometimes have fallen back on some mag sulfate IV - kind of hit or miss though. Lidocaine...never heard hide nor hair of that, even in old school stuff. SK Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted July 30, 2015 Share Posted July 30, 2015 I had thought that the Mg+ sulfate theory had been poo-poo'd. Cochrane review seemed to say "meh" in 2014. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 30, 2015 Author Moderator Share Posted July 30, 2015 do a search for ketamine for asthma, there are several articles showing benefit. Link to comment Share on other sites More sharing options...
fakingpatience Posted July 30, 2015 Share Posted July 30, 2015 What is the mechanism for the nebulized lidocaine working? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 30, 2015 Author Moderator Share Posted July 30, 2015 apparently it helps with cough(the same way tessalon does via helping with localized irritation) , but does not do much for asthma. Link to comment Share on other sites More sharing options...
cinntsp Posted July 30, 2015 Share Posted July 30, 2015 I had thought that the Mg+ sulfate theory had been poo-poo'd. Cochrane review seemed to say "meh" in 2014. Stole this from PC:RAP... IV magnesium. There were only about 665 patients who were randomized into trials to receive IV magnesium and the studies weren’t well done. This intervention needs more study. However, in these trials if you were a moderate or severe asthmatic, you had a 1 in 3 chance of avoiding admission if you received IV magnesium versus placebo. The NNT to avoid admission for moderate or severe asthmatics was 3. If you look at the 130 patients with severe asthma, they went from an admission rate of 90% to less than 50%. This was a number needed to treat of 2. We should be giving magnesium to anyone with moderate or severe asthma. Rowe, Brian H., et al. "Magnesium sulfate for treating exacerbations of acute asthma in the emergency department." Cochrane Database Syst Rev 2.1 (2000). Sent from my Nexus 5 using Tapatalk Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 30, 2015 Author Moderator Share Posted July 30, 2015 Thanks! Mg has been part of my severe asthma regimen for years. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted July 30, 2015 Share Posted July 30, 2015 Couple of Cochrane f/u's (Mg+) since 2000. Inhaled (12/12)? Meh. IV (7/09)? Conclusion: "...appears to be safe and beneficial in pt's who present with severe acute asthma." Also comments on refractory status to bronchodilators/steroids as indicator for such. IV (5/14 w/ 2313 pt's) effective for reducing admissions compared to placebo with no change in time in ED, BP, or RR. Cochrane findings are available for free online through interaction with Dr. Google :-). Sent from my iPad using Tapatalk Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted July 30, 2015 Moderator Share Posted July 30, 2015 Haven't heard of lido for asthma, but since I have pts get nebulized lido before an NG tube, I'd have little hesitation to use it for irritation from cough. It's certainly not going to relax bronchial smooth muscle. Haven't used ketamine for asthma yet (I've only intubated one asthmatic), but the next time I encounter that situation I'd most definitely use ketamine Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 30, 2015 Author Moderator Share Posted July 30, 2015 Haven't heard of lido for asthma, but since I have pts get nebulized lido before an NG tube, I'd have little hesitation to use it for irritation from cough. It's certainly not going to relax bronchial smooth muscle. Haven't used ketamine for asthma yet (I've only intubated one asthmatic), but the next time I encounter that situation I'd most definitely use ketamine it works well to help prevent the need for intubation and as an adjunct to bipap as well. Link to comment Share on other sites More sharing options...
sk732 Posted August 1, 2015 Share Posted August 1, 2015 Medscape article here: http://www.medscape.com/viewarticle/753225_2 Link to comment Share on other sites More sharing options...
Guest ral Posted August 1, 2015 Share Posted August 1, 2015 I remember using nebulized lidocaine at least 15-20 years ago for COPD exacerbations. About 10-20mg (1-2ml of 1% lido) seemed to work on some refractory patients. Haven't used it in many years, particularly due to other practitioners turning their heads sideways when I suggest it, and looking at me like my beagle does when I ask her if mommy is coming home soon. Mag is one of my usual go to drugs these days. Ketamine at a bolus of 0.1-0.75mg/kg has shown excellent effects for refractory asthma patients. The problem, as noted, is getting hospital worrywarts to approve of any policy involving it. Kind of along the same lines of reducing dislocations easily with a little push of propofol, and catching three kinds of hell from admin types, because there was no anesthetist standing right there. Crazy stuff, I tell ya. Link to comment Share on other sites More sharing options...
winterallsummer Posted August 6, 2015 Share Posted August 6, 2015 Nebulized lido? I will have to pass, personally. Hour long nebs, steroids, magnesium, NC and prepare for the worst. I have only seen heliox used when intubation is right around the corner. There is some data for LABA/ICS administration in the ED believe it or not, even though we are always taught it takes days for effect, but I have never done this personally. In my mind, once they are hit with mag, (consider triple) nebs and steroids, and had their blood work and CXR, then they either need to be tubed or set up for admission or discharge, I don't really do much else playing around past that in the ED. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 6, 2015 Author Moderator Share Posted August 6, 2015 I like to try in line albuerol w/ bipap + low dose ketamine and mag before intubation. it has turned folks around more often than not. they still get admitted, but go to tele instead of the icu. Link to comment Share on other sites More sharing options...
camoman1234 Posted August 6, 2015 Share Posted August 6, 2015 I like to try in line albuerol w/ bipap + low dose ketamine and mag before intubation. it has turned folks around more often than not. they still get admitted, but go to tele instead of the icu. I do not like any nebulizer inline unless the patient has an ETT. Even with an ETT, you will still get low % of medicine to the lung smooth muscles. Inline with bipap is the same thing as spraying albuterol via a water bottle into their face. I think this is very wasteful and I personally believe it is the PS that is helping that asthmatic more than the SABA/SAMA (atrovent). I always take them off bipap give treatment and then place back on. As for the Heliox (70/30 or 80/20), I LOVE this medicine and it does work. Can do heliox via NRB as well. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 6, 2015 Author Moderator Share Posted August 6, 2015 I do not like any nebulizer inline unless the patient has an ETT. Even with an ETT, you will still get low % of medicine to the lung smooth muscles. Inline with bipap is the same thing as spraying albuterol via a water bottle into their face. I think this is very wasteful and I personally believe it is the PS that is helping that asthmatic more than the SABA/SAMA (atrovent). I always take them off bipap give treatment and then place back on. As for the Heliox (70/30 or 80/20), I LOVE this medicine and it does work. Can do heliox via NRB as well. you can also do heliox with bipap and inline albuterol. my experience with bipap and neb tx has been very different. I have had folks who could not tolerate to get off bipap and the addition of the albuterol made a huge difference. these are folks who 5 yrs ago I would have just intubated because they were too fatigued to manage a neb tx, even by mask. Link to comment Share on other sites More sharing options...
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