All-Better-All

The wonder drug is wasting your time

I’m a respiratory therapist. For those of you not familiar with my profession—which is almost everyone—you can think of that as “like a very specialized nurse who does breathing and only breathing.” If there’s a job to be done to help a patient breathe and it’s more complicated than putting a nasal cannula¹ on their face, a respiratory therapist is probably on the job. If a respiratory therapist isn’t, it might be getting done wrong.

We do many different things, but the thing we’re best known for, around the hospital, is breathing treatments, so I’m going to start with that for my first post. Breathing treatments are straightforward: you assemble a little plastic doodad with a reservoir and mouthpiece, plug the tubing into the bottom, plug the other end of the tubing into the wall oxygen or air outlet, squirt a dab of the preferred drug into the reservoir, turn the outlet’s meter to eight liters per minute, and prepare for anywhere from two to twenty minutes of watching the patient inhale mist. How long depends on the model of nebulizer and how much stuff you put into it.

Usually, the stuff you put in is or contains albuterol, which is also the stuff in asthmatics’ rescue inhalers. I want to start off by saying that albuterol is a very, very good drug. I worked through respiratory school as a pharmacy tech, and compared to some other drugs², albuterol is incredible. It consistently delivers a clearly defined effect with minimal, manageable side effects, and it’s been around for so long that it’s dirt cheap.

Unfortunately, albuterol has become a victim of its own success. Cheap, safe, and makes a big impressive cloud of mist when you use it? I’ve just described the ultimate placebo. It’s become almost a cliche among respiratory therapists to complain about albuterol being ordered for things it simply doesn’t treat. You can get a wide variety of “albuterol doesn’t fix that” pins and badge-holders on Etsy, Pinterest or what-have-you.

So, what does albuterol do? It’s an adrenergic bronchodilator—it stimulates the body’s famed fight-or-flight response on (ideally) a purely local level, so that the rings of muscle lining your lower airway³ relax and open up and air can flow through. That’s it. That’s all it does. It tells your lungs there’s a bear about to attack so they can go to battle stations.

Now, albuterol is not perfectly selective for which receptor it targets, so some other parts of the body, notably the heart, might also hear about this bear and freak out too. That’s albuterol’s primary side-effect: rapid heart beat (tachycardia), jitters, feeling anxious. In my experience, it’s not really all that common.

Albuterol is quite literally a lifesaver for asthmatics and patients with COPD⁴ because bronchial constriction is their primary, extremely dangerous symptom. Everything clenches down and you can’t get air out effectively. Getting air in isn’t so hard, because when you inhale your airways stretch out with everything else, but exhalation? No good. Air is suddenly forced through a tiny little space, resulting in a whistling noise which everybody else hears as a wheeze. And, of course, if you can’t get the old stale air out, there’s no space for fresh air to come in.

But bronchial constriction announces itself to the world with a wheeze. Everybody knows that (even if they know nothing else about it). Patient is wheezing, therefore patient needs a breathing treatment. But wheezing is just the result of gas moving quickly through a narrow space. It can be caused by other things besides bronchial constriction. Here is a partial list of things which may cause wheezing and which albuterol cannot cure:

1. Fluid retention! This is probably the biggest culprit. If you are not urinating due to heart or kidney problems, fluid builds up in your body, eventually oozing out into your lung tissue⁵. This will also cause a wheezing noise. I have never been clear on why; my pet theory is that the excess fluid bulk causes everything to squish together on exhalation, since exhalation is normally an entirely passive process driven by the lungs’ elastic recoil. Fluid tends to give you a particular kind of wheeze, less a clean whistle and more of a rough sound that reminds me of the TIE fighters in Star Wars. But that’s not foolproof since a patient can have fluid retention problems and COPD at the same time, and the one can mask the other.

2. Just breathing too hard. Take a big breath and blow it out as violently as you can. It will sound wheezy, because you are trying to force too much air through too little space. Albuterol will not stop that. If a patient gets really worked up and breathing hard—this is easy with obese patients—they will sound wheezy. Hey respiratory! My patient is wheezing.

3. Upper airway issues. If the patient has something weird going on in the vicinity of their throat, such that it’s narrower than it should be, it will make a wheezing noise. What’s more, it will be a very loud wheezing noise you might be able to hear from the door. Scares the hell out of the nurse and the doctor. The nebulizer will not stop this, ever. The patient will nonetheless be on breathing treatments until they discharge. If you beg and plead with the doctor, arguing that they’re not in distress, that albuterol won’t fix it, etc., they might begrudgingly scale back treatments. Then the next doctor rotating in will notice that the patient is still wheezing and order increased treatments.

4. A COPD patient who is not in distress. Real bad COPDers are often silent in exacerbation; there’s not enough airflow to make noise even for a stethoscope. You give them the treatment and leave, two minutes later the nurse calls you because the patient is wheezing. Yes he is, dear. Because he’s fixed. He smoked for fifty years, now he’s a human bagpipe. Deal with it.

5. A nervous or panicking patient. They might or might not wheeze, but they feel like they can’t breathe, therefore they need a breathing treatment. This may exacerbate the tachycardia and make the problem worse.

6. Patient making a weird, transient lung noise that somebody, doctor or nurse, might decide resembles a wheeze more than anything else. You might not hear that noise when you show up, but you’d better give that albuterol, buster, or the nurse just might Advocate For Her Patient⁶ and the doctor will order a one-time stat dose to shut her cakehole. Then you’ll have to visit the room twice.

In addition, many physicians will err on the side of caution: “I do not know this patient’s medical history and cannot obtain it, possibly because they are bonkers. Therefore, they might smoke tobacco or worse. Therefore, they might have COPD. Aren’t they breathing kind of hard? Better order treatments.” Or the doctor might not even appreciate the whole bronchodilator part and order it for straight-up pneumonia, common cold, flu, you name it. There’s really no tactful way to tell them they’re fundamentally mistaken about what the drug does, unfortunately, so these errors will persist. Albuterol being so safe, many of them will order as-needed treatments for everyone as part of a standard orderset they click on a box for. Nobody is safe from unnecessary albuterol⁷, not even teen diabetics or clean-living old ladies with broken legs.

And that is why the majority of breathing treatments⁸, even in a good hospital, are going to be medically unnecessary. You, like the ordering physician, are probably just blowing smoke.

1. That plastic tube thingy that goes under the patient’s nose and blows oxygen in. Note that nasal cannulas are not idiot-proof; there is one right way, and surprisingly many wrong ways, to put them on. I very commonly find them put in upside down, such that the two prongs, instead of curving back to follow the internal anatomy of the nose, are pointing that O2 flow to the upper surface of the nares, for maximally irritating booger-drying efficiency. So actually, nurses can mess up the basic nasal cannula too, and in other, worse ways I won’t get into here. I don’t blame them for this; I’d probably screw up their job if I did any of it.

2. Looking at you, antidepressants!

3. Your trachea (windpipe) divides into two at a spot called the carina, forming the two mainstem bronchi leading to the two lungs. Within the lungs they split into bronchioles, which split and split again and again until they reach the alveoli, the little sacs where actual gas exchange occurs.

4. Chronic obstructive pulmonary disease, which I am not going to get into now. Maybe later. Think of it as “progressive nuclear slow-cooker death asthma that kills you for smoking cigarettes like a dummy.” The truth is of course more complicated, but that will do. Smoking gives you COPD with much higher frequency than it gives you cancer. Both are extremely unpleasant ways to die.

5. Sometimes into the airways themselves (pulmonary edema, the pink froth of doom), sometimes just into the surrounding tissue.

6. When a nurse, especially a young and idealistic nurse, Advocates for her Patient, the clouds part, and a ray of pure light descends upon her to illuminate her sincere and generous heart. This ray will shine on her even through the hospital roof and several intervening floors; experts are baffled as to why. But one eager RN Advocating for her Patient can spoil several dozen patients’ sleep with incidental light pollution. And also with unnecessary nebs.

7. As a matter of fact, most patients will not be on albuterol, they’ll be on albuterol and ipratropium, better known by the brand-name duoneb. Ipratropium is an anticholinergic bronchodilator, which is to say that while the albuterol is saying “open up” the ipratropium is saying “don’t close.” Albuterol is substantially more effective and the ipratropium is “helping” it in the same way Wallace Shawn’s character Vizzini from The Princess Bride might help the giant Fezzik lift an anvil. Strictly speaking, you get more lifting power with both of them, but if Vizzini keeled over and died you really wouldn’t notice the difference.

8. There are other nebulized drugs besides albuterol and ipratropium, but this post is long enough and frankly most of the others are of dubious utility for most patients anyway.