Duoneb with spiriva

Nuking my lungs tomorrow instead of Wednesday!

2023.11.21 05:47 DoubleOpposite2478 Nuking my lungs tomorrow instead of Wednesday!

I'm taking my Nucala autoinjector tomorrow instead of Wednesday in the hopes of climbing out of this two week+ flare up of my eosinophilic asthma. I've nicknamed it "nuking my lungs". Been alternating DuoNeb and Albuterol neb treatments almost everyday in addition to my 4× daily Cromolyn Sodium neb treatments and my 2 puffs 1× daily Spiriva Respimat 2.5 mcg. I'm allergic to all forms of steroids so there's that little fun piece as well. Dx'd with asthma at age 5 and turned 33 on July 15th of this year. Anyone else in a flare thanks to the wonderful weather rollercoaster here in the US?

submitted by DoubleOpposite2478 to eosinophilic_asthma [link] [comments]

2023.08.06 12:43 Alarming_Way_6296 Switching Meds

Hey guys, I'm hoping to get some perspective, I've been managing asthma and copd with three daily inhalers: albuterol, symbicort, and Spiriva. I also take a whole manner of other meds (duonebs daily and a steady flow of prednisone). My doctor wants to take me off symbicort and Spiriva and start me on Brextri. Has anyone made this switch, or who takes brextri have any reviews? Symbicort is pretty much my anchor med, if that falls off, I get a flare-up, so I'm really anxious.

submitted by Alarming_Way_6296 to Asthma [link] [comments]

2023.06.16 09:13 megs1784 Predictable flares with eosinophilic dx?

Anyone else experience regular predictable flares? Suddenly developed asthma in 2019 and diagnosed eosinophilic in 2020. Personal history of immune related illness. But the flares occur the exact same way and follow the exact same trajectory every single time. Happens with documented frequency of 1x/6 weeks or so. If treated early it stops if left unchecked it gets worse until I am hospitalized and only prednisone breaks it at any point. The sooner I start the shorter the required course.
I am on every class of medication avaialable and currently 6 months in to Nucala after failing to respond to Fasenra. Eosinophils have been at 0 for months. I take symbicort singulair spiriva as well as albuterol and duonebs as needed. Regardless of the maintenance meds the flares have been the same sisnce i was diagnosed. Anyone have any similar experience?

submitted by megs1784 to Asthma [link] [comments]

2022.02.20 13:19 Infanatis Mother hospitalized/intubated, confused on labs (59/F)

My mother has been hospitalized for the most of February due to "COPD exasperation," and has been released from the hospital numerous times only to be brought back by the ambulance. Most recently she was released on the 18th while I was at work, and only a few hours later brought back to the hospital. I'm including the notes from this hospitalization + labs, which also gives a general history of her hospitalizations over this last month.
What I'm confused on is the discrepancy in her labs - why/how are her labs looking worse while intubated on a ventilator? Due to my hours, I can't go in and get an answer due to COVID protocols and limited visitation, and my phone conversations leave me even more confused.
I've tried to SS everything while redacting info for privacy, but it proved tedious - so I copy/pasted provider notes below, and recent labs can be seen here
I apologize if this is a lot, I can clean it up as best I can.

ED Triage Notes by , RN at 2/18/2022 11:25 PM

Pt BIB WMF from home after experiencing SOB at home. Upon EMS arrival, pt was in active respiratory distress, O2 in the 80s. EMS placed pt on CPAP and gave pt a duoneb and Solumedrol. Pt arrives tachypneic with labored breathing.

Nursing Note by , RN at 2/18/2022 12:25 AM

After being discharged, pt repeatedly (8-10 times) called back to the hospital to inquire about medications given during admission and medical questions. Pt also requested a medical release of information to be mailed to her house - educated pt about calling back in the morning to speak with medical records. Education given about discharge paperwork, pt responded with "I'm blind, that should be in the chart stating this." Medication pt requested given verbally over the phone with the patient. Pt stated that Apria did not change the bipap settings as they were here in the hospital during her admission - educated pt about speaking with Apria again. Informed MD Scott of the situation and he was told that Apria made the appropriate changes to the settings. Prior to taking pt down to the front emergency entry - educated about the importance of quitting smoking. Brother - Gordon picked up patient with no difficulties. Pt was on 5LNC O2 (same settings while she was waiting in the room to be discharged) when settled into the vehicle. No s/s of respiratory distress. Discussed with brother the importance of quitting smoking for the patient - his response "We have been telling her that for years." Pt and brother left with 2 tanks of full O2.

ED Provider Notes by Wu, MD at 2/18/2022 11:18 PM
EMERGENCY DEPARTMENT ENCOUNTER
Assessment & Plan
Patient presents to the emergency department emergently via EMS with chief complaint of shortness of breath. She has a long history of COPD and CHF, and recent admission to hospital for this. She was just discharged, but reportedly went home and started smoking again. EMS put her on CPAP, gave her inline DuoNeb and 125 mg Solu-Medrol. History limited secondary to critical nature of the patient in respiratory distress.
History is limited secondary to acuity of illness.
Patient is obtunded upon arrival. VBG demonstrates a pH of 7.1 and a PCO2 of 116. At this plan, decision was made to perform rapid sequence intubation. Ketamine and rocuronium was used and she was intubated without difficulty.
ED Course as of 02/19/22 0047
Sat Feb 19, 2022
0024 WBC White Blood Count(!): 28.6 [MW]
0024 pH, Venous (POC)(!): 7.21 [MW]
0024 pCO2, Venous (POC)(!): 79 [MW]
0025 pH, Venous (POC)(!!): 7.11 [MW]
0025 pCO2, Venous (POC)(!): 117 [MW]
0044 Discussed with Dr. , with ICU. He agrees with admitting the patient and further management. CTA of the chest also ordered. [MW]
0044 Sepsis alert initiated. [MW]
ED Course User Index
[MW] Ming-Jay Jeffrey Wu, MD
Sepsis core measure:
Infection was first suspected after WBC.
The patient met SIRS criteria if two or more were present: See nurse's notes and HR > 90
The criteria for acute organ damage was based on: AMS (GCS < 13)
The onset time of severe sepsis occurred when the organ damage criterion was met or when infection was first suspected, whichever came later.
The sepsis alert protocol was initiated.
Blood cultures were drawn before antibiotics.
Antibiotics were broad spectrum or based on culture data.
An initial lactate was obtained.
The initial lactate was elevated and was repeated.
30 cc/kg of crystalloid fluid was administered based on ideal body weight because of BMI > 30.
Vasopressors were not indicated (either the patient was not hypotensive after the fluid bolus or oscillometric hypotensive readings in the hour after the fluids were not felt to be reflective of true hypotension requiring vasopressors).
I performed a sepsis focused exam. Time of exam: 02/19/22 at 12:46 AM MST
My critical care time in the management of severe sepsis as described above was at least 45 minutes, excluding procedures.
CLINICAL IMPRESSION:
Final diagnoses:
Acute on chronic respiratory failure with hypoxia and hypercapnia (CMS/HCC)
COPD with acute exacerbation (CMS/HCC)
ED Prescriptions

None

COMPLAINT / HISTORY OF PRESENT ILLNESS
CHIEF COMPLAINT: Respiratory failure
HISTORY OF PRESENT ILLNESS:
Patient presents to the emergency department emergently via EMS with chief complaint of shortness of breath. She has a long history of COPD and CHF, and recent admission to hospital for this. She was just discharged, but reportedly went home and started smoking again. EMS put her on CPAP, gave her inline DuoNeb and 125 mg Solu-Medrol. History limited secondary to critical nature of the patient in respiratory distress.
ROS: Limited secondary to acuity of illness. As is my standard practice, ALL positives from the ROS are documented in the HPI.
PAST HISTORIES / MEDICATIONS / ALLERGIES
Past Medical History:
Diagnosis Date
• Ambulates with cane
• Asthma
• Cataracts, bilateral
• COPD (chronic obstructive pulmonary disease) (CMS/HCC)
• GERD (gastroesophageal reflux disease)
• Hemoptysis 3/18/2019
• Hypertension
• Neck mass 9/12/2017

Formatting of this note might be different from the original. Last Assessment & Plan: H/O recurrent cystic neck masses, patient recall poor Patient concerned today for a posterior neck mass. Submental fullness on exam. CTA ordered for eval of neck and mass- she has not done this yet. She says she had a carotid ultrasound last week, but I do not see this in her chart- will request records from

• Obesity
• On home oxygen therapy

6LNC

• Pneumonia 3/18/2019
• Smoker
• Unemployed

pt states she is unemployed due to Covid. Own mobile salon, multiservice =junk, cleaning, organization company.

Past Surgical History:
Procedure Laterality Date
• BREAST SURGERY
• OOPHORECTOMY
• THROAT SURGERY
• TUMOR REMOVAL

chest wall

Family History
Problem Relation Age of Onset
• Breast Cancer Unilateral (or unspecified) Mother's Sister 69
• Stroke Mother
• Heart disease Father
• Hypertension Mother
• Heart attack Father
• Diabetes Father
• Obesity Father
Social History
Tobacco Use
• Smoking status: Current Every Day Smoker
Packs/day: 0.50
Years: 40.00
Pack years: 20.00
Types: Cigarettes
• Smokeless tobacco: Never Used
• Tobacco comment: pt is quitting; down to 8 cigs a day
Vaping Use
• Vaping Use: Never used
Substance Use Topics
• Alcohol use: No
• Drug use: No
ED Current OP Medications

Medication Sig Dispense Start Date End Date Doc. Provider albuterol 2.5 mg /3 mL (0.083 %) nebulizer solution Inhale 3 mL (2.5 mg) by nebulization every 4 hours as needed for wheezing. 90 mL 7/8/2020 , MD albuterol 90 mcg/actuation inhaler Inhale 1-2 puffs by mouth every 6 hours as needed for wheezing. 54 g 1/29/2022 2/28/2022 , DO amLODIPine (NORVASC) 5 MG tablet Take 1 tablet (5 mg) by mouth daily. May take additional 5 mg in the morning if BP is elevated during the day 30 tablet 2/18/2022 3/20/2022 , MD aspirin 325 MG EC tablet Take 1 tablet (325 mg) by mouth nightly. 30 tablet 2/18/2022 3/20/2022 v, MD atorvastatin (LIPITOR) 20 MG tablet (Expired) Take 1 tablet (20 mg) by mouth nightly. 30 tablet 4/8/2021 2/2/2022 , MD azithromycin (ZITHROMAX) 250 MG tablet Take 1 tablet (250 mg) by mouth 3 times a week. M W F 12 tablet 2/18/2022 3/20/2022 , MD famotidine (PEPCID) 20 MG tablet Take 1 tablet (20 mg) by mouth 2 times a day. 60 tablet 3/27/2021 , MD fluticasone propion-salmeteroL (ADVAIR) 500-50 mcg/dose DISKUS Inhale 1 puff by mouth 2 times a day. Historical Provider, MD furosemide (LASIX) 20 MG tablet Take 1 tablet (20 mg) by mouth daily. 30 tablet 2/19/2022 3/21/2022 , MD guaiFENesin (MUCINEX) 1,200 mg tablet extended release 12hr ER tablet Take 1 tablet (1,200 mg) by mouth 2 times a day. 60 tablet 2/18/2022 3/20/2022  MD loratadine (CLARITIN) 10 mg tablet (Expired) Take 1 tablet (10 mg) by mouth daily. 30 tablet 3/28/2021 2/2/2022 , MD LORazepam (ATIVAN) 0.5 MG tablet Take 1 tablet (0.5 mg) by mouth every 4 hours as needed for anxiety. 21 tablet 2/18/2022 2/25/2022 , MD predniSONE (DELTASONE) 10 MG tablet Take 4 tablets (40 mg) by mouth daily with breakfast for 4 days, THEN 2 tablets (20 mg) daily with breakfast for 4 days, THEN 1 tablet (10 mg) daily with breakfast for 6 days. 30 tablet 2/19/2022 3/5/2022 , MD tiotropium bromide (Spiriva Respimat) 2.5 mcg/actuation mist Inhale 5 mcg by mouth daily. Historical Provider, MD

Allergies
Allergen Reactions
• Penicillins
Tolerates cephalosporins
PAST MEDICAL RECORDS: A search through past medical records was made. Relevant findings are outlined in the history of present illness, otherwise the findings are not relevant to this visit, or there are no documented emergency department visits that I could find within our system.
PHYSICAL EXAMINATION
ED Triage Vitals [02/18/22 2329]
Temp Pulse Resp BP SpO2
36.6 °C (97.8 °F) (!) 138 (!) 22 (!) 233/109 98 %
Temp Source Heart Rate Source Patient Position (BP) BP Location FiO2 (%)
Temporal -- -- Right arm --
PHYSICAL EXAM:Vital Signs reviewed. See below for details.
Constitutional: Obtunded, appears ill
HENT/Head: Normocephalic
Eyes: Conjunctivae are normal
Neck: Neck supple
Cardiovascular: Tachycardic
Pulmonary/Chest: Tachypneic, with prolonged expiratory phase
Abdominal: Benign
Musculoskeletal: No deformity
Neurological: Obtunded
Skin: No pallor
Psychiatric: Obtunded
ED COURSE / PROCEDURES / DIAGNOSTICS
MDM
DIFFERENTIAL DIAGNOSIS (prior to diagnostic data acquisition):
COPD exacerbation, CHF, pneumonia, COVID-19, among others
ED COURSE & TREATMENTS:
Vitals:

02/18/22 2328 02/18/22 2329 02/18/22 2330 02/19/22 0000

BP: (!) 233/109 (!) 206/110 121/81
Pulse: (!) 138 (!) 136 (!) 134
Resp: (!) 22 (!) 22 18
Temp: 36.6 °C (97.8 °F)
TempSrc: Temporal
SpO2: 98% 99% 99%
Weight: 116 kg (255 lb 11.7 oz)
Height: 170.2 cm (5' 7")
Medications
albuterol 2.5 mg /3 mL (0.083 %) nebulizer solution 15 mg (has no administration in time range)
cefTRIAXone (ROCEPHIN) 2 g in sodium chloride 0.9 % 20 mL IV solution (has no administration in time range)
ketamine (KETALAR) 1000 mg in sodium chloride 0.9 % 250 mL (4 mg/mL) infusion (premix) (has no administration in time range)
propofoL (DIPRIVAN) 10 mg/mL infusion (premix) (60 mcg/kg/min × 118 kg intravenous Rate/Dose Change 2/19/22 0042)
etomidate (AMIDATE) 2 mg/mL injection - ADS Override Pull (has no administration in time range)
albuterol 2.5 mg /3 mL (0.083 %) nebulizer solution - ADS Override Pull (has no administration in time range)
lactated Ringer's bolus bolus 1,848 mL (has no administration in time range)
rocuronium injection 100 mg (100 mg intravenous Given 2/18/22 2334)
ketamine (KETALAR) 50 mg/mL injection - ADS Override Pull (250 mg Given 2/18/22 2333)
ipratropium (ATROVENT) 0.02 % nebulizer solution - ADS Override Pull (0.5 mg Given 2/18/22 2341)
LABS ORDERED AND REVIEWED:
Labs Reviewed
BASIC METABOLIC PANEL - Abnormal; Notable for the following components:
Result Value

CO2 Carbon Dioxide 33 (\*) Glucose 155 (\*) All other components within normal limits

BNP PROBRAIN NATRIURETIC PEPTIDE - Abnormal; Notable for the following components:

BNP Pro Brain Natriuretic Peptide 165 (\*) All other components within normal limits Narrative: Interpretation Guidance for BNP Pro

Patients presenting with acute dyspnea
BNP Pro values <300 pg/mL have 99% negative predictive value for excluding acute congestive heart failure (CHF) at any age.
A cutoff of 1,200 pg/mL for patients with an eGFR <60 yields a diagnostic sensitivity and specificity of 89% and 72% for acute CHF
50-75 years of age
A diagnostic BNP Pro cutoff of 900 pg/mL has been suggested in adults 50 to 75 years of age in the absence of renal failure
BNP Pro values 300-900 pg/mL grey zone with heart failure possible depending on clinical history
LACTATE VENOUS - Abnormal; Notable for the following components:

Lactate, Venous 2.1 (\*) All other components within normal limits

BLOOD GAS VENOUS - Abnormal; Notable for the following components:

pH, Venous (POC) 7.21 (\*) pCO2, Venous (POC) 79 (\*) HCO3, Venous (POC) 32 (\*) O2 Saturation, Venous (POC) 98 (\*) All other components within normal limits

CBC WITH DIFFERENTIAL REFLEX MANUAL DIFF - Abnormal; Notable for the following components:

WBC White Blood Count 28.6 (\*) Neutrophils Absolute 17.63 (\*) Immature Granulocytes Absolute 1.47 (\*) Lymphocytes Absolute 6.8 (\*) Monocytes Absolute 2.5 (\*) Basophils Absolute 0.2 (\*) All other components within normal limits Narrative: Slide referred to Pathologist for review

This is an appended report. These results have been appended to a previously verified report.
POC BLOOD GAS VENOUS - Abnormal; Notable for the following components:

pH, Venous (POC) 7.11 (\*) pCO2, Venous (POC) 117 (\*) HCO3, Venous (POC) 37 (\*) BE Base Excess, Venous (POC) 3 (\*) All other components within normal limits

POC GLUCOSE - Abnormal; Notable for the following components:

Glucose (POC) 160 (\*) All other components within normal limits

POC LACTATE, VENOUS - Abnormal; Notable for the following components:

Lactate, Venous (POC) 2.2 (\*) All other components within normal limits

POC CREATININE BLOOD - Abnormal; Notable for the following components:

Creatinine (POC) 1.03 (\*) GFR Glomerular Filtration Rate (POC) 59.6 (\*) All other components within normal limits Narrative: Units = mL/min/1.73 m2

GFR results <60 for 3 months or longer: Chronic kidney disease
GFR results <15: Kidney failure
If African American is indicated, calculation includes multiplier of 1.159.
Formula used is the CKD-EPI equation.
POCT TOTAL CO2 - Abnormal; Notable for the following components:

CO2 Total (POC) 39 (\*) All other components within normal limits

HEPATIC FUNCTION PANEL - Normal
TROPONIN HIGH SENSITIVITY - Normal
POC HEMATOCRIT - Normal
POCT CHLORIDE - Normal
POCT UREA NITROGEN - Normal
POCT SODIUM - Normal
POCT POTASSIUM - Normal
POCT IONIZED CALCIUM - Normal
POC HEMOGLOBIN - Normal
POCT ANION GAP - Normal

Narrative: Anion gap = (Na+K)-(Cl+HCO3)

(HCO3=TCO2-1)
CULTURE BLOOD (2 SETS)

Narrative: The following orders were created for panel order Culture Blood (2 sets).

Procedure Abnormality Status
--------- ----------- ------
Culture Blood[434268230] In process
Culture Blood[434268232]
Please view results for these tests on the individual orders.
CULTURE BLOOD
CULTURE BLOOD
COVID-19 PCR DIAGNOSTIC
CULTURE URINE
CULTURE RESPIRATORY WITH GRAM STAIN
CBC AND DIFFERENTIAL

Narrative: The following orders were created for panel order CBC with Differential reflex Manual Diff.

Procedure Abnormality Status
--------- ----------- ------
CBC with Differential re...[434268228] Abnormal Final result
Please view results for these tests on the individual orders.
CBC CELLAVISION DIFFERENTIAL
TROPONIN HIGH SENSITIVITY
PATH COMMENT HEMATOLOGY
LACTATE VENOUS
TESTS AND IMAGING ORDERED AND REVIEWED:
XR Chest 1 View AP Portable
Result Date: 2/19/2022
Appropriately placed in GE and endotracheal tubes. Thank you for this referral. This examination was interpreted by a Colorado Imaging Associates radiologist. Providers with questions may reach a radiologist directly at 303-223-4448. WS: LFIELDING-HOME- DICTATED BY: MIKETIC-FIELDING, LINDA Date: 02/19/2022 00:01 MT TRANSCRIBED DATE: 02/19/2022 00:01 MT
Procedures
Procedure: Endotracheal Intubation
Consent: Emergent
Indication: Respiratory failure and airway protection
Description: Patient was preoxygenated.
Induction agent: Ketamine
Paralytic: Rocuronium
Patient was intubated using a 3.0 glide scope blade with 7.5 ET tube
Tracheal position of ETT was confirmed using direct visualization, ETCO2, tube fog, ausculation. Breath sounds were auscultated equally. Chest xray confirms ETT in good position.
Complications: None
Disposition: Procedure well tolerated with no immediate complications.
Procedure was performed by myself
MEDICINE SECTION OF CPT: Ordered and Reviewed
O2 Sat: 98% BiPAP
OBTAIN HISTORY FROM SOMEONE OTHER THAN THE PATIENT:
EMS
INDEPENDENT VISUALIZATION OF IMAGES, TRACINGS, OR SPECIMENS:
12 lead EKG:
Indication: Respiratory failure
Rhythm: Sinus tachycardia, rate of 135
Axis: Normal
Intervals: Normal
QRS: Normal
ST segments: Normal
INTERPRETATION: Sinus tachycardia
The 12 lead EKG was interpreted by myself.
DISCUSSED THE PATIENT WITH ANOTHER PROVIDER:
All Consulting Physicians - Current Visit Chat With All Active Members

Provider Specialty From To v, DO Critical Care 02/19/22 0029 —

Critical care
Risk of Complications, Morbidity, and/or Mortality:
Presenting Problems: High. Critical Care

submitted by Infanatis to AskDocs [link] [comments]

2020.12.27 03:06 92_Explorer If a hospitalized patient is having difficulty breathing (assuming it's 100% not COVID related), how do you decide which breathing treatment to give?

There are so many different breathing treatment options that I see given to hospitalized patients. There's Duoneb, Atrovent, Pulmicort, Xopenex, Spiriva, racemic epi etc... that I can name off the top of my head, but I know that there are a ton more that I've seen ordered for hospitalized patients, usually by the internal medicine residents.
I understand the MOA for each of these individual and combination medications, and I understand how they get escalated from one to the other in someone with asthma or COPD presenting in the outpatient setting because there is a stepwise increase for these, but I don't really have a framework for how these medications get used in the hospital for a patient who doesn't have any type of official diagnosis and is simply experiencing difficulty breathing.
What is the approach that you take here? The one I most often see used is Duoneb (ipratropium/albuterol), but is there an algorithm that is employed here, or is it more of user preference and guess work?
There are so many countless combinations of steroids, beta2s and cholinergics even within a single hospital that it becomes daunting to try to parse out when to use which one. All I really can think of is that if someone suddenly becomes short of breath use short acting medication and if someone is always at baseline short of breath use long acting, but outside of that, I have no clue when to use one over the other and why.
Any tips?

submitted by 92_Explorer to Residency [link] [comments]

2018.08.08 11:06 lobbed_abroad [Question] Why is arformoterol (brovana) contraindicated for asthma - why is there an increase in asthma related deaths? And, any information about giving brovana and Albuterol to one patient multiple times per day.

Our hospital recently decided to stop administering all MDI's to patient's, even if they use them at home. If a patient is on Spiriva at home, they now get Atrovent Q6. Advaisymbicort is now arformoterol (Brovana)/Pulmicort BID.
Now, we're getting patients in that take Advair at home, so, Brovana/Pulmicort BID, and the doctor orders Duoneb Q4 around the clock.
So, twice a day, our patient's are getting Duoneb, Brovana, Pulmicort.
We keep asking our medical director and pharmacy director if we should be giving Albuterol Q4, plus Brovana BID. They say it's okay.
Also, we've been looking up more information on Brovana and came across literature saying it is contraindicated for patients with asthma, and could lead to an increase in asthma related deaths.
Anyone have anymore information on this that could help us understand a bit more?
Our reasoning is that asthma patients are not being properly educated and are using brovana as a rescue medication.

submitted by lobbed_abroad to respiratorytherapy [link] [comments]

2017.07.18 02:58 jmc781 Drug cheat sheet? ( MDIs and Nebs ), or any cheat sheets !

Hi there ! I'm new to Respiratory and I was wondering if anyone had any good drug cheat sheets. I'm having difficulty finding a good one online. I would like something to cross reference when docs order new nebs and MDIs. For instance , if a doc orders Spiriva and Duoneb - suggesting a change. I could make one but I want to make sure I'm not missing anything ! Especially with all the different inhaler brands out there.
Since I'm a new grad any cheat sheets you have or have used while you got used to your workflow would be appreciated :D (or even any useful apps you found ) thanks in advance !

submitted by jmc781 to respiratorytherapy [link] [comments]

http://activeproperty.pl/