echidna

A few Saturdays ago I completed a day’s training in Remote Asthma Management.

Lengthy background (superfluous to main questions)

Having only suffered from just one attack back in high school years, I am aware of the suddenness and lack of warning which an asthma attack gives, even to seemingly healthy individuals. As such, asthma is a constant worry to me, less so for myself but more for others & I’ve always carried a Ventolin inhaler in both my home & travel first aid kits.

I gather that several years ago the Australian Government classed Ventolin & such bronchodilators as Type 3 medications, meaning that they can only be purchased with advice and consultation with a chemist (pharmacist). But further & here’s what angers me, being a Type 3 medication, First Aiders are not qualified to administer Ventolin without appropriate additional qualification, not included in current Australian First Aid qualifications.

As such, the training recommendation is that a First Aid Kit should not contain Ventolin unless all first aiders are officially qualified (which is as yet not easily organised & likely prohibitively expensive. IOW, better to watch passively as a colleague or child suffocates from asthma, than risk a lawsuit from administering Ventolin, a drug which I understand to be overwhelmingly harmless. In fact the dosages we were officially taught were actually in the order of 10 times higher (since they are recommended through an extender chamber), than the couple of direct puffs from the inhaler itself which I was taught maybe 20 years ago. Nonetheless, even those few puffs are potentially life-saving as compared with no treatment at all.

I volunteer with a church group (non-proselytising of course) which takes disabled kids on weekend activities & often being unfit, part of our agenda is sometimes to give them some exercise which they may not be so accustomed to. And over the past 3 years asthma has been a constant worry of mine, less so for those already diagnosed since they usually come with their own medications, but more so for the first-time attack, the unexpected. I’m pleased that the group responded with the training, but at the same time I question whether this is a case of over-regulation. Hell, we’ve created a legal jungle where we’re trained to distance ourselves from responsibility at all costs, that some schools even discuss no longer administering band-aids (sticky-plasters ?) for fear of litigation.

Our official training lasted 6 hours & from that I can probably teach someone how to administer Ventolin, in the space of 15 minutes. But instead, each person needs to go through this 6 hour, $100 course, something which our volunteer group can ill afford. And now we have a situation that on a camp which I’m running we can carry Ventolin, but if another camp director hasn’t received this “official” training, we have to take the Ventolin out. I find this far from satisfactory, & yet another reason to vent my dislike of lawyers.

Questions :

1. Why the fuss over Ventolin ? I understand it to be largely harmless & in the event of an asthma attack, it will be the difference between life and death. Is its classification appropriate ? How do other countries deal with bronchiodilators ?

2. (Why) is childhood asthma apparently on the increase ? Our trainer actually responded that likely it isn’t, that third world countries simply don’t recognise it as a problem and so don’t report it. But at the same time I’ve seen many reports claiming that childhood incidence is on the increase. Anecdotally this seems to be true from where I stand, that my parents & grandparents don’t remember asthma as they were growing up, and yet today every second kid seems to have experienced some degree of asthma.
The main reasons I have seen are a) increased use of chemicals & b) lack of household bacteria caused by over-use of disinfectants. Certainly Australia seems to be an asthma capital of the world.

3. (moral rather than scientific) Is it better to administer a drug with a known risk, than to withhold it in order to avoid the risk of wrongful dosage ?

Godot

1. The problem in this country relates largely to public liability insurance (damn HIH...). I have no direct knowledge with Ventolin, so I will avoid that part of the question (if only school was this easy!).
2. I would dispute your trainer's claim. In increased incidence of asthma could be partially compensated through better detection methods, but how does Third World detection relate to Australian incidence/prevalence rates? I would opine that the increased rates are largely due to higher levels of environmental contaminants (particularly as we shift to a predominantly urban society. There may be something in thoughts about lack of pathogens and a bored (read: inactive/underactive) immune system, but that is a line of reasoning that necessitates further research.
3.Drugs that are available to the general public (with or without a prescription) have already been subjected to rigorous clinical trials to gauge the appropriate dosage levels to offset the risk/benefit issue. Before clinical trials approach the human subject stage, the same degree of testing is performed on animals. Throughout (and before), the pharmacokinetics of a given drug are monitered to ensure that the treatment modality used is appropriate given the likely physiological effects of a given drug.
If you find yourself in a position that you must administer a drug to someone, it should be presented to you in a pre-selected dosage so that this ethical dilemma does not eventuate. You must also take into consideration the results of inaction on your part: does inaction cause a greater degree of harm to the individual than an incorrect dosage would?
If it appears that such a situation may arise, it would be prudent of you to find an amenable solution to the problem before the need to put the plan into action arises.

Torben

As for 2), let me add here from cold and windy Scandinavia that much-improved insulation of housing after the oil crises of the 70s is being hypothesized to add to indoor dust particles and dust mites. This may not be a significant factor in Australia

Torben

ps418

As with anything else, there are genetic susceptibilities interacting with environmental triggers. Obviously the increased incidence of asthma over the past several decades, assuming that its not an artifact of improved diagnosis, has to be explained by reference to environmental factors of some sort.

Your hypothesis b) is basically the "hygiene hypothesis"of asthma, which is gaining some experimental support. For example, it was recently demonstrated in a mouse model of asthma that specifically early exposure to the bacterium Mycoplasma pneumoniae significantly moderated subsequent allergic responses, a result the authors interpret as evidence for the hygiene hypothesis (Chu et al, 2003). You can find lots of additional info by searching PubMed and Google for "hygience hypothesis."

That all depends on the relative risks. With some drugs you can't afford even a single wrongful dose. With others, a wrong dose is no big deal.

. . . . .

Chu et al, 2003. Effects of Respiratory Mycoplasma pneumoniae Infection on Allergen-Induced Bronchial Hyperresponsiveness and Lung Inflammation in Mice. Infection adn Immunity 71:1520-1526.

MadKally

I am a RN and am qualified to not only administer Ventolin, but do a tracheotomy and most other medical acts in an emergency. I carry Ventolin with me. The trunk of my car looks like an ambulance. A Ventolin inhaler has a metered dose. You can't give too much.

But if wasn't a nurse, I would not hesitate saving a person's life. Laws be damned!

Kally

echidna

Cheers Godot. Kally, yes, Ventolin is metred, but at the same time we're taught to administer 4 doses every four minutes, four times, so the metering alone doesn't limit the dosage quantity. I gather that these bronchiodilators are steroids. Is there any risk as such, given that the term steroid has such a poor reputation ?

Is this the only risk for its regulation the irrelevant technicality that it's linked to the term "steroid" ?

Thanks for the Hygiene Hypothesis link, Patrick.

Jackalope

No, ventolin and other bronchodilators are not steroids. Corticosteroids are used as maintanence drugs to *prevent* attacks, not as rescue drugs once an attack has started. Ventolin is a beta-agonist, a synthetic relative of epinephrine (adrenaline). Giving too many metered doses could cause cardiac problems, but respiratory failure is an immediate emergency all by itself. Severely allergic individuals should carry an epi-pen or similar form of injected epinephrine. If that's not possible because of heart problems or other severe side effects, the next most common injected rescue drug used here in the US is Benadryl.

The ventolin inhaler or epi-pen is meant to keep you breathing until you can get to the emergency room. Any diagnosed asthmatic should be using a peak flow inhaler to monitor their lung function and have an emergency plan from their doctor. If you're below a certain range on the peak flow meter, you call the doctor. Even further below, you get yourself to the ER. Far too many patients wtih asthma haven't done any of that, which makes it awfully easy to get into trouble.

Inhaled corticosteroids like Flovent, Azmacort or Pulmicort are meant to keep the inflammation levels down low enough that attacks don't happen. Or if they do happen, they're not nearly as severe. It's only in the last 10 years or so that it's been commonly accepted that constant inflammation of the lungs can eventually cause scarring. Scarring can lead to reduced lung volume and eventually chonic obstructionary pulmonary disease (COPD, the newer descriptive term for emphysema).

Serevent is a slow-acting beta-agonist, but it also has a 12 hour duration, so it can help prevent middle of the night attacks. The other slow-acting drugs that are sometimes used are mast cell inhibitors like Intal or Tilade and an atropine derivative called Atrovent. There's also Combivent, which is Atrovent and Ventolin in the same inhaler.

[argh, looking at my collection of inhalers]

echidna

Thanks Jackalope. I've seen Ventolin confused as a steroid before. I suppose the epinephrine is why it often stimulates recipients, affecting drowsiness if taken just before bedtime. Cheers.

Oolon Colluphid

In Britain at least, salbutamol inhalers such as Ventolin come in dispensers exactly the same shape as steroid inhalers, but are distinguished by being blue rather than the brown (becotide) or orange (flixotide) of the others. This may be the cause of the confusion.

I have tried to overdose on Ventolin, just to see what happens (very puffed, took some, then some more, then some more; was just out of breath really, but must've had about 25 puffs in maybe two minutes) and the worst effect was feeling slightly wobbly. I'd say you're likely to have hyperventilation problems long before you've taken enough to harm you, simply from trying to take enough to harm you.

To paraphrase the old UK blood donation slogan:
Give Ventolin, not excuses.

DT

Vashtarah

I agree that ventolin is a wonderful thing to have in a first aid kit and that "training" to administer it shouldn't cost any amount of money or take that long.

I have suffered from asthma since I was 3 or 4 and now, at the age of 20, my asthma is just as bad as it was 10 years ago and shows no sign of going away.

I use my albuterol inhaler (generic of Ventolin) about once a day, one or two puffs per usage. Just last night I woke up with an attack because I forgot to take my theophylline, which regulates my asthma on a daily basis. When I have forgotten to take the theophylline and wake up with an attack, I hit the inhaler pretty hard. I might take 4 to 6 puffs in a two minute period and, while this clears everything up enough for me to sleep, I am guaranteed a NASTY headache in the morning. I've taken as many as 8 in a panic and I was truly sorry the next day.

Now, I use my albuterol exactly as I was taught at the age of 5 or something. First I breathe out and get rid of as much air as possible, then I "puff" the inhaler and inhale at the same time. This maximizes the amount of drug I get to my lungs. Maybe this is what makes 4 puffs hit me like a ton of bricks the next day. I have to wonder if 4-6 hits gives me one hell of a headache (and sends my heartrate up quite a bit), would 25 hits (administered as I do) do some major damage?

I'm not a medical professional, but speaking from personal experience, if 4 or 6 hits doesn't help I don't keep trying because I'm afraid of overdose. I've also found that the effectiveness of albuterol doesn't really increase with the number of puffs. The only thing getting bigger is the intensity of tomorrow's headache. I get myself to the air compressor for the albuterol vapor or I get myself to a hospital.

I guess my question is, do they teach in training that there is a limit to the number of doses you should administer? My doctors have always said "no more than 2 per hour" and I break the rules when I have an attack at night. Four doses every four minutes, four times is really unfathomable to me, but maybe I've never had an attack get that out of control.