Are we Overusing DuoNebs in the Emergency Department?
I'm not sure I've got the answer to that question. I'm writing this article to learn for myself the answer and to see what you, the readers, have to say about this issue.
We've got a couple of doctors in our emergency department that will order a DuoNeb (albuterol and ipratropium combined into one nebulizer treatment) for every single patient that comes in the door. And then we have some doctors that are a tad more sparing than that, but will order a duoneb for every patient that comes in with respiratory distress and even sometimes in chest pain patients who sound more like respiratory cases.
And then on the opposite side, we have some respiratory therapists (RTs) in our emergency department that are dead set against ordering DuoNebs for everyone. We've got one RT in our department that just about down right refuses to give a duoneb to most of the patients that one gets ordered for.
My real questions are: who's in the right? Should we give them to anyone and everyone just in case? Are they indicated for the majority of the respiratory patients that come in to our ED? Or are they being dramatically overused with very little efficacy in most patients?
So first, we must break down DuoNebs themselves: What are they? A nebulizer treatment that consists of 0.017% ipratropium bromide and 0.083% albuterol.
According to Epocrates, DuoNebs are indicated for COPD daily and moderate to severe asthma exacerbations. So is is safe and effective when we use it for our COPD exacerbations? And is it a good idea to use it for patients that do have a history of asthma and perhaps their visit is due to an exacerbation? So many more questions that what we started out with...
After looking at some recent research on the topic, I discovered that yes, DuoNebs can be very effective in the event of an acute COPD or asthma exacerbation.
Are they useful in non-acute scenarios? Well, yes for COPD and asthma.
Are they useful for patients that come in that might have a small case of pneumonia or bronchitis or even an exacerbation of congestive heart failure and they aren't in any significant respiratory distress? Probably not, the cheaper treatment of albuterol on its own is probably just fine. The ipratropium component of the DuoNeb isn't going to help in many of the circumstances we use it in. We only need the albuterol.
Are they useful in emergency respiratory distress that has nothing to do with asthma or COPD? No. Racemic epinephrine is better indicated.
Are they being overused in the ED? Based on the research, I believe so. The more expensive duoneb really should only be reserved for patients that have a known history of COPD or Asthma AND are presenting with one of them as their chief complaint.
Otherwise, the cheaper alternative of albuterol alone will work just fine.
So what are your thoughts on DuoNebs in your nursing travels? Yay or Nay?
References:
https://online.epocrates.com/u/1012491/DuoNeb/Adult+Dosing
https://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-emergency-department-management
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4950546/
https://www.jems.com/welcome.html?destination=/articles/print/volume-35/issue-5/patient-care/how-treat-shortness-breath.html
We've got a couple of doctors in our emergency department that will order a DuoNeb (albuterol and ipratropium combined into one nebulizer treatment) for every single patient that comes in the door. And then we have some doctors that are a tad more sparing than that, but will order a duoneb for every patient that comes in with respiratory distress and even sometimes in chest pain patients who sound more like respiratory cases.
And then on the opposite side, we have some respiratory therapists (RTs) in our emergency department that are dead set against ordering DuoNebs for everyone. We've got one RT in our department that just about down right refuses to give a duoneb to most of the patients that one gets ordered for.
My real questions are: who's in the right? Should we give them to anyone and everyone just in case? Are they indicated for the majority of the respiratory patients that come in to our ED? Or are they being dramatically overused with very little efficacy in most patients?
So first, we must break down DuoNebs themselves: What are they? A nebulizer treatment that consists of 0.017% ipratropium bromide and 0.083% albuterol.
According to Epocrates, DuoNebs are indicated for COPD daily and moderate to severe asthma exacerbations. So is is safe and effective when we use it for our COPD exacerbations? And is it a good idea to use it for patients that do have a history of asthma and perhaps their visit is due to an exacerbation? So many more questions that what we started out with...
After looking at some recent research on the topic, I discovered that yes, DuoNebs can be very effective in the event of an acute COPD or asthma exacerbation.
Are they useful in non-acute scenarios? Well, yes for COPD and asthma.
Are they useful for patients that come in that might have a small case of pneumonia or bronchitis or even an exacerbation of congestive heart failure and they aren't in any significant respiratory distress? Probably not, the cheaper treatment of albuterol on its own is probably just fine. The ipratropium component of the DuoNeb isn't going to help in many of the circumstances we use it in. We only need the albuterol.
Are they useful in emergency respiratory distress that has nothing to do with asthma or COPD? No. Racemic epinephrine is better indicated.
Are they being overused in the ED? Based on the research, I believe so. The more expensive duoneb really should only be reserved for patients that have a known history of COPD or Asthma AND are presenting with one of them as their chief complaint.
Otherwise, the cheaper alternative of albuterol alone will work just fine.
So what are your thoughts on DuoNebs in your nursing travels? Yay or Nay?
References:
https://online.epocrates.com/u/1012491/DuoNeb/Adult+Dosing
https://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-emergency-department-management
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4950546/
https://www.jems.com/welcome.html?destination=/articles/print/volume-35/issue-5/patient-care/how-treat-shortness-breath.html
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