RT refused to give NEB!

[chenoaspirit]

At our facility, RT administers all nebs. We have a patient who is in with aspiration pneumonia. His O2 sat was in low 80s and was in distress. He asked for a treatment, which was amazing because he has been literally too sick to speak for about a week. He had scheduled nebs plus PRN nebs q2h. RT was already on the floor and I asked her if she would give him a neb. Her response was "well, you know nebs are not a cure-all". I kindly said "I never said they were, but he is needing one and its time for one. If you dont want to, or dont have time to, I can do it myself." She said "uh, no, you cant because only RT can administer nebs". lol. I casually asked the coordinator later about it and of course we are aloud to give nebs. I dont know why, but RT gets infuriated when we ask them to administer any PRN neb. I know they are busy, but that is their job and nebs are ordered for a reason.

[usalsfyre]

I've been hearing, "If they're not wheezing a treatment isn't needed"!

:

Considering that albuterol is only effective in reversing bronchospasm, and doesn't act in any other areas than the bronchioles, why the headbanging? Wheezing/bronchospasm is the indication, not pneumonia, aspiration, ect.

[usalsfyre]

Where I work this has been an ongoing problem. The RT's now have a policy that states they will determine if Nebs are appropriate for every patient who has them ordered and will change them to MDI's if they feel it is appropriate. Essentially all Neb orders get changed to MDI's, even in the ICU. They same policy autosubs albuterol for levalbuterol even when albuterol is ordered specifically, even by a pulmonologist.

The basis for equating MDI's to nebs is based on a study that showed similar effectiveness for MDI's when compared to Nebs, although the subjects were stable and were using the MDI's for maintenance therapy, not exacerbations or in the precence of other illnesses. What they missed is that MDI's were only shown to be as effective when "optimal technique" was used. So then the next question is how many patients are capable of "optimal technique" with use of an MDI's? One study showed it to as low as 10%. Another study looked at MD's, RN's, and RT's ability to assist and instruct patients on optimal use, which found that only 39% of RN's, 48% of MD's passed "rudimentary" MDI skills. Only 67% of RT's were capable of monitoring and instructing patients on optimal MDI use.

The same policy also automatically D/C's all orders for levalbuterol and replaces it with albuterol, even if it is the patient's home med.

If the patients unable to properly use an MDI, then they need a neb. Otherwise an MDI is a cheaper option that more closely matches what they will most likely use at home.

As for the levalbuterol vs albuterol, the Xopenex is vastly more expensive with little to no clinical benefit.

[MunoRN, RN]

If the patients unable to properly use an MDI, then they need a neb. Otherwise an MDI is a cheaper option that more closely matches what they will most likely use at home.

As for the levalbuterol vs albuterol, the Xopenex is vastly more expensive with little to no clinical benefit.

In patients experiencing asthma or COPD exacerbations, particularly older COPD patients, the difference in xopenex vs racemic albuterol is signficant, including decreased inpatient admission rates when used in the ED, shorter lengths of stay, lower 30-day readmission rates, lower rates of adverse effects such as paradoxical bronchospasm, decreased beta effects (due to decreased total dosage), and decreased overall use.

The main study that critics of xopenex point to is the Quereshi et al study. This study was done on mild to moderate severity asthma exacerbations in young patients, which is not the target group for xopenex. The study also was seriously flawed in the use of steroid therapy as a control. Racemic albuterol contains both the ® and (S) isomers of albuterol. The (S) isomer was once thought to be inert, although once we gained the ability to separate ® and (S) albuterol and perform research on each isomer, it became clear that the (S) isomer exerts pro-inflammatory effects, which explains why xopenex, which is only ® albuterol is more effective even at lower doses than racemic albuterol with the same amount of the "active" ingredient ® albuterol; the pro-inflammatory (S) albuterol is working against the anti-inflammatory effects of ® albuterol. Essentially, racemic albuterol is a poison and an antidote packaged together. Using a steroid as a control is like testing the effects of a poison while using the antidote as a control and then declaring the poison is not poisonous after all.

There once was a time when xopenex was much more expensive than racemic albuterol, although probably still cheaper when you consider admission rates and lengths of stay, although levalbuterol is now generic, making the price difference about $3 a day.

[MunoRN, RN]

If the patients unable to properly use an MDI, then they need a neb. Otherwise an MDI is a cheaper option that more closely matches what they will most likely use at home.

Matching the patient's home routine is fine if the patient is admitted for something other than what they take the bronchodilator for. What's really frustrating, for Nurses MD's and patients, is when RT puts a patient on their home routine who was just admitted for a COPD exacerbation. Obviously their home routine wasn't sufficient, if it was they could have just stayed at home. What really frustrates patients is that in the ED they get xopenex (our ED doesn't even stock racemic albuterol), then come to the floor and go back to racemic MDI's and usually lose any progress they made in the ED.