Your Captain Speaking: Albuterol—Getting the Medicine Where It Counts

Dick: Samantha, I had a pulmonary function test (PFT) today and the hospital technician, Rebecca, handed me Albuterol for the last of the five tests. A series of past EMS calls immediately came to mind.

You roll up on a patient who is tight, wheezing, and working hard to breathe. The protocol is clear: Albuterol. You reach for the nebulizer or the inhaler, start the treatment, and load for transport. But how much of that medicine is actually reaching the lower airways where it can do the job?

Albuterol is one of the most-used medications in EMS, and it’s one of the easiest to deliver poorly. Getting it right isn’t complicated, but it does require attention to detail. Many organizations have replaced Albuterol with Duoneb, which is a combination of Albuterol and Ipratropium. Duoneb is only delivered as a nebulizer treatment but for purposes of this article we can treat them as the same—these drugs only help if they get to the right place in the lungs.

Standard Protocols and Delivery Options

Most EMS protocols authorize Albuterol or Duoneb for patients with bronchospasm from asthma, COPD, or reactive airway disease. The usual adult dose is 2.5 mg of Albuterol sulfate nebulized with oxygen at 6–8 L/min. Many systems allow a second or third dose if the patient is still in distress and hasn’t developed significant side effects. Pediatric dosing is weight-based or follows a standardized unit dose of 2.5 mg in most current protocols. Some systems also allow continuous nebulization for severe, persistent bronchospasm.

The other common route is the metered-dose inhaler (MDI). When an MDI is used for patients, protocols typically call for four to eight puffs—but only one at a time. Treat and then reassess. The key phrase that should appear in every protocol is “with spacer” or “with valved holding chamber.” That detail isn’t optional if you want the medication to work as intended. After the patient inhales, they need to hold their breath for about 10 seconds to keep it in their lungs.

Why the Chamber Matters

A nebulizer creates a continuous aerosol that the patient breathes over several minutes. A properly set-up nebulizer with a good mask or mouthpiece and the correct oxygen flow delivers a steady dose. It doesn’t require much coordination from the patient. In some cases, an inline nebulizer treatment with a CPAP, BiPAP, or BVM needs to be used. If your patient is awake, these can require some coaching to get the medication where it needs to go.

An MDI is different. The medication is delivered in a high-velocity burst that lasts less than half a second. Without a spacer or valved holding chamber, a large portion of that dose impacts the back of the mouth and throat and never reaches the lower airways. Studies consistently show that a spacer or valved holding chamber improves lung deposition and reduces oropharyngeal deposition. The spacer improves the delivery to the lungs by up to 50% to 70%. In many cases, an MDI with a spacer is as effective as a nebulizer for mild-to-moderate exacerbations and produces fewer side effects such as tachycardia, tremors, and dry throat.¹

When a patient is too short of breath to coordinate a good inhalation, or when the patient is a child, the chamber becomes even more important. A mask attached to the chamber can be used for patients who can’t seal their lips around a mouthpiece. Skipping the chamber is the single-most common delivery error seen in the field.

Common Mistakes EMS Makes

The most frequent error is using an MDI without a spacer. It looks faster, but much of the dose is wasted. The second most common mistake is poor patient coaching. Simply handing the patient an inhaler and saying “breathe in” is not enough. The patient needs to sit upright, if possible, form a good seal, actuate the inhaler at the start of a slow deep breath, and hold the breath for several seconds (10 seconds normally) if able.

Other frequent slip-ups include:

• Failing to shake the MDI vigorously before each use.
• Using the wrong oxygen flow rate on a nebulizer (too low and the medication doesn’t aerosolize properly; too high and the treatment finishes too quickly or the medication is blown past the patient).
• No reassessment after the first treatment. Lung sounds, work of breathing, respiratory rate, and pulse oximetry should be checked before and after. Documenting these are also of high importance.
• Especially if using a mouthpiece on a continuous delivery set-up, asking the patient a bunch of questions during the treatment. We have a lot of questions in EMS, but just let them breathe in the treatment.
• If the patient is too obtunded to hold the mouthpiece in their mouth or too distracted to hold the mouthpiece in place, switch to mask delivery.
• Continuing treatments without watching for side effects such as marked tachycardia or tremors, especially in older patients or those with cardiac history.
• Assuming continuous nebulization is always better. For many patients, intermittent treatments with reassessment between doses are more appropriate and allow you to track improvement.
• As discussed in the previous EMS World article Your Captain Speaking: When Patients Say “No”—Handling Refusals in the Field, completing the treatment on-scene could have the patient refuse transport because “I’m feeling better now. I don’t want to go to the hospital.” In our mind this would be a high-risk refusal. Someone having a hard time breathing is a big deal. Load into the ambulance and give treatment en route.

A less-obvious but important mistake is treating the symptom without considering the bigger picture. Not every wheeze is pure bronchospasm. Cardiac asthma, pulmonary edema, and anaphylaxis can all present with wheezing. Albuterol won’t fix those problems and may complicate them.

Putting It Into Practice

When you reach for Albuterol, ask yourself two quick questions. First, is this the right medication for this patient? Second, am I delivering it in a way that gets the drug into the lungs?

If you are using a nebulizer, make sure the mask or mouthpiece fits, the oxygen flow is correct, and the patient is positioned to maximize inhalation. If you are using an MDI, put a chamber on it every time. Coach the patient. Watch the technique. Reassess after the treatment.

Albuterol is a reliable medication when it reaches the right place. Your job is to make sure it does. The difference between a treatment that works and one that doesn’t is often nothing more than a spacer and a few seconds of careful instruction.

Be deliberate. The patient is counting on the medicine actually arriving where it’s needed.

Samantha: Dick, you and I have seen these mistakes with Albuterol over the years. It’s not a frequent topic in continuing education as there are so many topics to cover. The list is spot on!

References

1.  Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulizers for beta-agonist treatment of acute asthma. Cochrane Database of Systematic Reviews. 2013;(9):CD000052. doi:10.1002/14651858.CD000052.pub3

About the Authors

Dick Blanchet, (Retired) BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, MO, and Illinois for more than 22 years. As a Captain with Atlas Air for 22 years on the Boeing 747, he has more than 21,000 flight hours. A USAF pilot for 22 years, he flew the C-9 Nightingale Aeromedical aircraft and retired as a Lt. Colonel. A USAF Academy graduate with a Bachelor of Science degree, his Masters in Business Administration is from Golden Gate University. Email contact- ACLS911@aol.com

Samantha Greene is a paramedic and field training officer for the Illinois Department of Public Health Region IV Southwestern Illinois EMS system, a paramedic and FTO for Columbia (IL) EMS, and was a full-time paramedic and House Supervisor at the St. Louis South City Hospital Emergency Department. She was previously recognized as a GMR Star of Life.