Duovent (bronchodilator) nebulizer and CPAP therapy

[Pneumophile]

Here is an interesting facet of CPAP therapy that some here on the forum may be familiar with but that is entirely new to me. In talking today with the pulmonary therapist administering Duovent (a combination bronchodilator therapy given via nebulizer) to a relative of mine in a hospital setting, I mentioned CPAP therapy and wondered how being on a blower might complicate matters for the therapist. She said that Duovent can be administered to a patient who is using a CPAP machine by adding a T-tube to the line and connecting one of the ports to the Duovent nebulizer. In this way the bronchodilator can be administered to the patient while he or she is on a CPAP machine during the night without disturbing them. The therapist said that this technique is not as successful when nasal masks are used; full face masks are much preferable.

Has anyone seen a nebulizer being used in conjunction with CPAP in this way, or had it actually done to them?

[Note: Duovent is a combination of ipratropium bromide (anticholinergic agent) and fenoterol hydrobromide (beta2 adrenergic receptor agonist), both of which are bronchodilators. The nebulizer machine creates a mist of the solution which is inhaled through a mask.]

[Goofproof]

Here is an interesting facet of CPAP therapy that some here on the forum may be familiar with but that is entirely new to me. In talking today with the pulmonary therapist administering Duovent (a combination bronchodilator therapy given via nebulizer) to a relative of mine in a hospital setting, I mentioned CPAP therapy and wondered how being on a blower might complicate matters for the therapist. She said that Duovent can be administered to a patient who is using a CPAP machine by adding a T-tube to the line and connecting one of the ports to the Duovent nebulizer. In this way the bronchodilator can be administered to the patient while he or she is on a CPAP machine during the night without disturbing them. The therapist said that this technique is not as successful when nasal masks are used; full face masks are much preferable.

Has anyone seen a nebulizer being used in conjunction with CPAP in this way, or had it actually done to them?

{Duovent is a combination of ipratropium bromide (anticholinergic agent) and fenoterol hydrobromide (beta2 adrenergic receptor agonist), both of which are bronchodilators. The nebulizer machine creates a sort of mist which is inhaled through a mask.]

Sounds to me like you need some advice....

Put on some earphones turn them up loud. So you won't be hearing what others say.

Put on sleep blinders so you won't see what others around you are doing.

Take some Chill Pills and relax, let the world go by, you need to unwind. Jim

[allenrcp]

I've seen it done in the hospital setting for convenience. Not sure why someone would elect to go this route at home though... It doesn't seem terribly inconvenient to administer a treatment the standard way. If you must know though... The nebulizer should be placed in line as close to the patient as possible -like between the mask and tubing otherwise therapeutic effects will be reduced as the medication will wind up on the inside of the tubing as opposed to inside of your lungs. Again this method is not recommended as most nebulizers work best in a level position so that can become more difficult than it's worth and secondly a possibility of leaks.

[Pneumophile]

The therapist said that bronchodilator therapy was effective when done in conjunction with CPAP so drug loss in the tubing probably isn't a big problem. I don't think the technique is used very often - no need for CPAP during the day when this nebulizer therapy is usually given (typically 4 times per day, 8 min sessions).

Goofproof: very strange post.

[palerider]

Goofproof: very strange post.

it's his way.

[Goofproof]

Goofproof: very strange post.

it's his way.

Yep, some people need to wear hats with nets mounted on top, that way they can catch what goes over their heads. Jim

[nanwilson]

The therapist said that bronchodilator therapy was effective when done in conjunction with CPAP so drug loss in the tubing probably isn't a big problem. I don't think the technique is used very often - no need for CPAP during the day when this nebulizer therapy is usually given (typically 4 times per day, 8 min sessions).

Goofproof: very strange post.

Actually "Doc" you and the therapist have it a bit wrong.............. I have three different nebulizers and have to wash them out every little bit, because the spray from the bronchodilator "sticks" to the inside of the carrier. Can you imagine how sticky your mask and tube would get???? I have to even rinse my mouth out when I use my alvesco (ciclesonide) twice a day. How hard is it to take your mask off, use your puffer and mask back up. I'm sure the instructions that you received where very little used or needed.

[avi123]

As I understand it, patients on Ventilators are intubated and don't need CPAP machines. Ventilators could be adjusted to work as CPAPs. But if a person is intubated and is on a Ventilator then a CPAP would not open his/her airway because there is a tube there already opening the airway. If you want to try a CPAP on the patient then the tube needs to come out. The nebulizers are attachments to provide medications. To wean patients from Ventilators takes several days and need to be done properly. Weaned patients could always use CPAPs at home if needed later.

[allenrcp]

As I understand it, patients on Ventilators are intubated and don't need CPAP machines. Ventilators could be adjusted to work as CPAPs. But if a person is intubated and is on a Ventilator then a CPAP would not open his/her airway because there is a tube there already opening the airway. If you want to try a CPAP on the patient then the tube needs to come out. The nebulizers are attachments to provide medications. To wean patients from Ventilators takes several days and need to be done properly. Weaned patients could always use CPAPs at home if needed later.

On a vent the terminology changes from CPAP to PEEP. The two are synonymous in terms of what is being delivered to the patient,positive airway pressure, but the indications differ. PEEP is used to aid in the recruitment of collapsed alveolar sacs on patients with refractory hypoxemia whereas CPAP prevents pharyngeal airway collapse during sleep. The post was originally referring to placement of a t-tube in line on a CPAP with a spontaneously breathing patient. In which case the t-piece can only be in installed at a joint in the line. So take your pick between mask and tubing or between PAP device and tubing. Choosing the later means the sleeping patient would not have to be disturbed and when time is of the essence (hospital setting) it is a convenient but albeit less effective way administer a nebulizer treatment. There will be substantial particle rain out and deposition on the tubing walls. Will some medicine get through? Sure. Some. But a therapist recommending this is the product of having too much to do in too little time. The point to the original poster... they don't call it a hand held nebulizer for nothing.

Alvesco is an mdi so its not going to go in a nebulizer but the same concept applies. You don't see anyone trying to suck an inhaler through 3 feet of tubing.

[palerider]

On a vent the terminology changes from CPAP to PEEP. The two are synonymous in terms of what is being delivered to the patient,positive airway pressure, but the indications differ. PEEP is used to aid in the recruitment of collapsed alveolar sacs on patients with refractory hypoxemia whereas CPAP prevents pharyngeal airway collapse during sleep.

I believe that PEEP is actually analogous to EPAP, since it only refers, by definition, to (Positive) End Expiratory Pressure, whereas CPAP also is referring to IPAP, and in all but the most simple cpaps, the IPAP and EPAP can be different.

[allenrcp]

I believe that PEEP is actually analogous to EPAP, since it only refers, by definition, to (Positive) End Expiratory Pressure, whereas CPAP also is referring to IPAP, and in all but the most simple cpaps, the IPAP and EPAP can be different.[/quote]


Speaking in terms of ventilator settings the physiologic effects of CPAP and PEEP are increased FRC. In that way, EPAP will also have the same FRC increasing effect. No vent order I have ever heard includes EPAP unless we are talking NIPPV and then it is half of a BiPAP order.

[palerider]

I believe that PEEP is actually analogous to EPAP, since it only refers, by definition, to (Positive) End Expiratory Pressure, whereas CPAP also is referring to IPAP, and in all but the most simple cpaps, the IPAP and EPAP can be different.

Speaking in terms of ventilator settings the physiologic effects of CPAP and PEEP are increased FRC. In that way, EPAP will also have the same FRC increasing effect. No vent order I have ever heard includes EPAP unless we are talking NIPPV and then it is half of a BiPAP order.

you seem to have missed the point.

[Pneumophile]

The pulmonary therapist made it clear that she was talking about CPAP and not artificial ventilation when she referred to use in conjunction with a nebulizer - she said that it is NOT done with a ventilator. The T junction is placed between the short tube attached to the CPAP mask and the long tube to the CPAP machine, i.e. as close to the mask as possible. There will presumably be some loss of drug in the tubing but not so much as to make the nebulizer ineffective. Of course the advantage of this arrangement is that the nebulizer can be used without disturbing the patient at night.

[lathnos46]

Just as an aside, I have had a terrible case of bronchitis, bordering on pneumonia, for almost two weeks. I have noticed that Apap therapy has helped me greatly in breathing at night. That positive air pressure has helped to open up my bronchial tubes and at least while sleeping I have not coughed. Chalk one up for Cpap therapy!

[Goofproof]

[quote="Pneumophile"]The pulmonary therapist made it clear that she was talking about CPAP and not artificial ventilation when she referred to use in conjunction with a nebulizer - she said that it is NOT done with a ventilator. The T junction is placed between the short tube attached to the CPAP mask and the long tube to the CPAP machine, i.e. as close to the mask as possible. There will presumably be some loss of drug in the tubing but not so much as to make the nebulizer ineffective. Of course the advantage of this arrangement is that the nebulizer can be used without disturbing the patient at night.[/quote

I take it, the patient is awake when the pulmonary therapist, uses the nebulizer, making cpap not necessary. Basically the pulmonary therapist is too lazy to remove the cpap mask and do their job, so they cut a corner, so they can go back to sleep. Is the treatment given with the patient awake and in a upright position? Giving the treatment lying down doesn't sound good.

It just sounds to me like your expert pulmonary therapist,and or their employer, cares less about the patient that 5 minutes of time. Jim