Indications for albuterol tx.

nurs4kids · Oct 21, 2001

Originally posted by juliekrn
Does anyone know of a scoring system or resource that describes indications for albuterol use in children with respiratory distress? Last winter, I spent a lot of time arguing with our respiratory therapists that wheezing was not the only indicator for albuterol tx. Also, how do you deliver oxygen to infants and children and is it always humidified? Thanks.

Julie,

I was going to leave this one alone, because I don't have alot to add, but didn't want you feeling ignored. I see others have looked and not responded, so I suspect they, like me have little knowledge on this. I have never heard of a scoring system for albuterol treatments. We use them, of course, with wheezing, but also with generalized congestion. We deliver O2 vial face mask, nasal cannula, ambu bag or blow-by (just blowing into the face). Preferably it should always be humidified so not to irritate the nasal and oral passages. Occassionally, we will run straight 02 for short periods of time while a patient is off the unit for procedures (found this is better than having a patient sprayed with h20 from an overturned tank).

Hope this helps,

Tracy

bbnurse · Nov 10, 2001

We don't have guidelines nor criteria for albuterol tx. except for the nurse's own assessment of the child. If there are OTHER symptoms of respiratory distress then the child should have the treatment. We spent much of the past two winters arguing with RT about whether the child needed a treatment or not. Especially if the kid was satting somewhere close to 90 %. They would argue that if there was a good sat, then we were nuts to ask for the treatment. We were even told that the kids would be better off not to have the treatments so frequently---even with MAJOR symptoms of respiratory distress. We had two presentations about RSV this summer to" get us all on the same page" but the last kid we had with resp. distress, we still had an argument with the RT who said he didn't agree with the Dr. who presented the education supporting the entire assessment as the criteria to give the treatments. He bad-mouths the entire peds staff cause we call for treatments so often. Yet the kids are blue, retracting, wheezing and struggling so.... makes me angry at his arrogance. Well, HE hasn't had a kid code from lack of ability to breathe...JERK.

**canoehead, BSN, RN** · Nov 10, 2001

I've found that the two hospitals I've worked at in the US are less aggressive with albuterol than the one I came from. They use much more oxygen and tend to have a longer length of stay. In Canada we would give nebs to minimize wheezing, not just to minimize visible distress. We used about half the o2, and all involved recognized the implications of very little wheezing but an increasing o2 requirement- the child's lungs are actually so tight they cannot wheeze, and after the extra neb you should start to hear insp/exp wheezing. It sounds worse, but tells you that they are moving air where they weren't before.

When RT's are needed to administer a neb, not only can it be delayed because of all their other duties, but the kids don't get the benefit of continuous reassessment by one person, and the RT's are understandably reluctant to hike all the way to another floor to do an extra Rx, their time is tight too, and it screws up the routine they've set out for themselves to get everyone done. Not to mention the ego punch when a nurse does a respiratory assessment.

I think that one person coordinating all the care makes much more sense, especially when you are trying to get a cranky toddler to sleep. Also with a window of say 30min around treatments it is perfectly acceptable to give one early, and then have the next given late, and with someone on Q2H nebs you've just increased their between neb time by 50%.

My own opinion- RN's have to be trained in all the RT treatments because RT's may not be available, esp at night. If we still carry ultimate responsibility for the patient care and still have to keep track of the timing of treatments and the patient's response I would much rather do it myself, and maybe get an extra RN added to the staff mix. We have the flexibility to try giving the neb a little earlier or later and do more frequent assessments, and then base the next Rx on small gains or losses, makes for much more personalized care.

I also think that if a child's O2 sats start to drop say 2h after their Q3H treatment that the nebs should be incresed to Q2H, EVEN if more O2 will bring them up.

kids · Nov 12, 2001

Arrrgh! Some times I really HATE RTs'

I have never worked in acute peds. I do peds homecare. Every one of our kids has some sort of respiratory problem. The stories some of the parents come back from an admit with burn me. The 2 latest are:

3 yo profoundly retarded/blind/deaf/CP sitting up in bed clutching rails, a few scattered wheezes I/E, wants the O2 mask ON, sats are 90% on 3 liters. RT walks in, says the sats are fine (Um...baseline sats are 99-100 on RA, I think his brain cells would like a little more please) and he doesn't need a neb tx, tries to do the MDI, kid can't understand/communicate/cooperate. RT charts refusal and leaves.

A&O X4 8 yo SMA, trach & vent since 11 months. Suctioning Q 5 min (thank God for skilled parents @ bedside), high pressuring almost constantly , no wheeze, CPT/PD done, sats 96% (baseline) and good movement with sxn...RT says she doesn't need a tx.

Heres the kicker: BOTH admitted by their PCP with orders that state: Albuterol 0.083% ud via HHN Q 10 min PRN SOB,respiratory distress, increased sectetions, O2 requirements > 2 lpm.

So even having 'good orders' doesn't matter sometimes.

And the Doctors sometimes wonder why we work so hard to manage these kids at home first.

-nancy

**canoehead, BSN, RN** · Nov 12, 2001

I sometimes wondered if the RT's I dealt with cared about anything more than getting through the shift.

Unfortunately they don't have the ime or resources to experiment with stretching and shortening times between neb treatments, and if they don't try making the changes on a regular basis they will not be comfortable with doing it.

After 6 y of doing my own nebs on peds I was pretty confident about my ability to listen to lung sounds and predict the results of a neb because we listened before and after EVERY neb. We'd also listen Q15min if necessary to pinpoint the exact time that the kids started to tighten up so we could stretch just a little further next time. I've gone a 12h shift knowing that the RT listened ONCE, and not before and after RX. How do they know if the kid needs another Rx if they don't know the worst sounding chest(before) and the best(after) that this kid can produce?

Jeez, this is one of my sore spots. Especially when an RT tells me I don't know what I'm doing, and I'm the ONLY one who has listened to the kid's chest all night.

And when the doc on call goes with the RT recommendation and the DOC hasn't listened either.

I'll stop ranting.

RTreformed · Aug 19, 2006

wow, you know what, you people are absolutely right. WHEEZING is not the only indication for albuterol, because, rhonchi, rales, upper airway edema and any other inflammation can cause wheezing. the only indication for albuterol, is actual BRONCHOSPAM. albuterol is a beta 2 agonist, causes the smooth muscle walls of the airway to relax when they are having bronchospam. nurses believe that they "need a tx" anytime they hear adventitous breath sounds... for every 200 calls i receive about patients "needin a tx", 1 of those pts actually has bronchospam and benefits from it... also, albuterol does NOTHING for a pts sats, period. and for those of you who will say "ive seen their sats come up", next time, notice if the RT is giving the neb on medical air, or OXYGEN, hello? im not lazy, i dont mind doing my job, cause, im damn good at it, but i absolutely HATE doing any type of modality that is unindicated. and i hate the RN way of thinking "well, it wont hurt them, we should try it", you know what, 0.25 morphine wont hurt them either, so lets try it as well? now do you see the idiotic logic?

jamie p rakes RRT

vaughanmk · Aug 27, 2006

We use albuterol a lot where I work, in the ED. A lot of kids are too tight to wheeze upon arrival. We also use it for a cough occasionally. Most children without a history who come in with resp distress of any manner recieve albuterol. Frequently mixed with atrovent too.

RTreformed · Aug 28, 2006

We use albuterol a lot where I work, in the ED. A lot of kids are too tight to wheeze upon arrival. We also use it for a cough occasionally. Most children without a history who come in with resp distress of any manner recieve albuterol. Frequently mixed with atrovent too.

and again, wrong usage... tell me how a bronchodilator does anything for a cough? wouldnt robitussin work better?

KellieNurse06 · Aug 28, 2006

and again, wrong usage... tell me how a bronchodilator does anything for a cough? wouldnt robitussin work better?

I have been told a cough can also be a sign of tight airways...and when the kids cough it's because it's almost like a reflex to clear the airways or get air in......and it is alot of times bronchospasms.....

I also have had a problem with a respiratory therapist who comes to my house for my child.......everytime she would come to do her vent check and whatnot..she would check off on her little paper she had to turn in every time she came that patient (my kid) was "always confused" ........problem I had with that is..she's never so much as went over to my kid and even said one word to her...so how would she know she's confused?????? :nono:

Ya..there are some awesome resp therapists.....and there are some real winners too..........

gauge14iv, MSN, APRN, NP · Aug 28, 2006

and again, wrong usage... tell me how a bronchodilator does anything for a cough? wouldnt robitussin work better?

A cough can be the single presenting symptom of bronchospasm, even in the absence of wheezing.

How about cough variant asthma?

rninme · Aug 28, 2006

Was going to stay out of this one....lol.....RRT for 18 years before becoming an RN. Albuterol is for bronchospasm....not for a cough. Also....albuterol CAN NOT swim....therefore....if a patient is full of secretions....it is not going to get to the receptor site. Ditto with rales. Low spo2's....give o2. Another lesson in albuterol world.....give TOO much....and it will cause refractory wheezing (bronchospasm).

In ED....if we get anyone with a tight refractory wheeze not helped by albuterol....we pull out the old gun...bronkosol....works every time!