Bronchial dialator question

[Aboveallislove]

Stupid question (again). How does chronic treatment with bronchial dialator's help those with CF? My understanding is it opens the airways. But what does it do for CF? I mean it doesn't think the mucus...and if there is no excerabation or shortness of breath, what is the way that it works prophelatically?

The reason I'm asking is this: We do 2x a day. Occassionally, if DS is coughing more than baseline (like after a day outside with lots of polland), I might do 3x. So what I want to discuss with the doctor is whether it makes sense to always do 3x a day (I would do the mid-day one with an inhaler and not nebulized, absent some issues). Or does doing 3x a day make it less helpful when there is an exacerbation? What would be the pros and cons of my thought? (Knowing how the opening the airways helps given what CF does, would help me think through this as I discuss with the doctor). I also would like to try him working on the inhaler without a spacer and thought that this would be perfect "practice" as it wouldn't be imperative that he get the entire dosing?

Thoughts???
Thanks

 

[Rebjane]

The way our pulmonologist explained it is that they use a lot of medications they use for asthma for CF but for a different purpose. We use albuterol for a bronchodilator(i.e. pre treat before Hypersal/pulmozyme) to get it deeper in the lungs. The respiratory tract in lined with cilia which are supposed to sweep upward to get rid of mucus. In CF the mucus is thick,sticky and weighs downs on the cilia so it won't work effectively... The bronchodilator can open things up so the mucus can be raised up and out(that's the idea)..Course everyone's different..

We do albuterol 3x a day(since my daughter was 2) and had a bad exacerbation. On school days, if she is healthy I'll do an inhaler for the afternoon treatment before afterschool activities like soccer/softball.

we also do not use a spacer for the inhaler, my reason is it would be one more thing to clean. My daughter's doc wants us to use the spacer; he said it is more effective butmy daughter has really good technique so we don't.

But of course, check with your CF doc...

 

[2005CFmom]

I had asked my doctor about this because my daughter's breathing test don't show an asthma component and I was questioning the need for albuterol. His answer was that in addition to being a broncho dilator, it also makes the cilia in the lungs beat faster to help sweep out the mucus. Don't know if there is a downside to doing and extra inhaler treatment.

 

[Aboveallislove]

The way our pulmonologist explained it is that they use a lot of medications they use for asthma for CF but for a different purpose. We use albuterol for a bronchodilator(i.e. pre treat before Hypersal/pulmozyme) to get it deeper in the lungs. The respiratory tract in lined with cilia which are supposed to sweep upward to get rid of mucus. In CF the mucus is thick,sticky and weighs downs on the cilia so it won't work effectively... The bronchodilator can open things up so the mucus can be raised up and out(that's the idea)..Course everyone's different..

We do albuterol 3x a day(since my daughter was 2) and had a bad exacerbation. On school days, if she is healthy I'll do an inhaler for the afternoon treatment before afterschool activities like soccer/softball.

we also do not use a spacer for the inhaler, my reason is it would be one more thing to clean. My daughter's doc wants us to use the spacer; he said it is more effective butmy daughter has really good technique so we don't.

But of course, check with your CF doc...

thats so helpful! And we are in in two weeks so I will of course run by doctor but wanted to think through what to say what to ask...what I wasn't getting is that they had DS on broncialdialtor at two weeks with no other mess...the getting deeper makes sense but I just didn't get how it worked preventative like but I can see if it is open it can get stuff out easier...I also wondered if it helps with inflammation. Yes, our doctor said re spacer same thing but beyond the extra thing to clean there is no real way to sterilize it...my thought is if it is extra on what we're doing now that would be good enough and it would improve technique! And if he is having problems I'd do the nebulizers one in any event! Thanks so much for thoughts

 

[Aboveallislove]

I had asked my doctor about this because my daughter's breathing test don't show an asthma component and I was questioning the need for albuterol. His answer was that in addition to being a broncho dilator, it also makes the cilia in the lungs beat faster to help sweep out the mucus. Don't know if there is a downside to doing and extra inhaler treatment.

wonderful! Thanks!

 

[Ratatosk]

We've always done albuterol and atrovent combined to open up the airways -- 3 times a day, more if exacerbations. Atrovent is a more longer lasting one. Other reason is when using tobi, helps to get the med deeper in the lungs AND if there are issues with bronchiospasms when using a harsher drug such as tobi, it helps with that.

 

[Aboveallislove]

We've always done albuterol and atrovent combined to open up the airways -- 3 times a day, more if exacerbations. Atrovent is a more longer lasting one. Other reason is when using tobi, helps to get the med deeper in the lungs AND if there are issues with bronchiospasms when using a harsher drug such as tobi, it helps with that.

thanks! What is Atrovent? Is there any downside to adding a third xopenex solo in the middle of the day!

 

[Ratatosk]

Generic is Ipratropium bromide. We mix it with albuterol (name brand of that mixture is duo-neb). While albuterol is a faster acting bronchodilator, atrovent is longer lasting. As for adding a third xopenex -- we've always done a bronchodilator when doing cpt or vesting. It's my understanding as long as the nebs are at least 4 hours apart. When ds had exacerbations as a baby or when his doctor had him do a clean out during his last bowel obstruction (6 years ago), we did nebs and cpt/vest at least 4 times a day --- orders were written for every 4 hours.

Oh and regular vesting/nebs schedule for us is 3 times a day. Before school, after school/work and before bed. Very rarely will we drop down to two treatments. If there's a special event that conflicts or when we've gone on a vacation like Disney where we end up getting lots of exercise (walking).

 

[Aboveallislove]

Generic is Ipratropium bromide. We mix it with albuterol (name brand of that mixture is duo-neb). While albuterol is a faster acting bronchodilator, atrovent is longer lasting. As for adding a third xopenex -- we've always done a bronchodilator when doing cpt or vesting. It's my understanding as long as the nebs are at least 4 hours apart. When ds had exacerbations as a baby or when his doctor had him do a clean out during his last bowel obstruction (6 years ago), we did nebs and cpt/vest at least 4 times a day --- orders were written for every 4 hours.

Oh and regular vesting/nebs schedule for us is 3 times a day. Before school, after school/work and before bed. Very rarely will we drop down to two treatments. If there's a special event that conflicts or when we've gone on a vacation like Disney where we end up getting lots of exercise (walking).

thanks! I would only add a third inhaled...I'm in awe that you are able to do three vests...I don't seem to have enough hours in the day...I'll have to talk with doctor re that other med..note resting it's never been mentioned.. Thanks for all the helpful info.

 

[jthomp]

Regarding not using the Spacer . . . My son gets very hyper with both Albuterol and Xopenex. After doing some research, we started using the spacer to help minimize negative side effects per our doctors recommendations and some other parents' experience. Even as an adult, I use the Spacer now as the side effects bother me also. Also helps eliminate mouth sores that inhaled steroids can cause.

 

[Aboveallislove]

Interesting...I would still use spacer for steroid since he definitely needs full dose...it would only be for an extra xopenex. Could you share the studies so I can review? Not that I'd know if he was hyper give his normal m.o. Thanks for input ...definitely will add to list for dr.

 

[The Dot]

Stupid question (again). How does chronic treatment with bronchial dialator's help those with CF? My understanding is it opens the airways. But what does it do for CF? I mean it doesn't think the mucus...and if there is no excerabation or shortness of breath, what is the way that it works prophelatically?

The reason I'm asking is this: We do 2x a day. Occassionally, if DS is coughing more than baseline (like after a day outside with lots of polland), I might do 3x. So what I want to discuss with the doctor is whether it makes sense to always do 3x a day (I would do the mid-day one with an inhaler and not nebulized, absent some issues). Or does doing 3x a day make it less helpful when there is an exacerbation? What would be the pros and cons of my thought? (Knowing how the opening the airways helps given what CF does, would help me think through this as I discuss with the doctor). I also would like to try him working on the inhaler without a spacer and thought that this would be perfect "practice" as it wouldn't be imperative that he get the entire dosing?

Thoughts???
Thanks

You do so well with him - what you teach him now will stay with him for the rest of his life - so please, do not stop using the spacer!!! If you want, I can find some of the studies and send to you that quantify the difference in the deposition of the medication with and without the spacer. With proper technique and a spacer, the inhaler can actually be better than the nebulizer! If you decide he does not need the mid-day treatment, just do not give it, but make this decision with the doctor.

Now - back to the original topic - why do bronchodilators for CF. I believe what they told us in RT school was that if you reduce the size of the airway by 1/2, then you increase the resistance to air movement by 16 times! Think about that - that is huge! And think how easy it is to reduce the size of the airway with secretions lining them. So, if you get even minimum effect from the bronchodilator, it is worth it because it is increasing the size of the airways. If your doc wants you to do a mid-day prophylactically (Gosh that's a hard word to spell!), I think I know where he is coming from. Given that CF patients have an abundance of secretions, it's a miracle any bronchodilator ever makes it to the beta-receptors in the lungs (given it is a beta-adrenergic like Albuterol). If the airway is already dilated, you stand a much better chance of the medication getting to the beta-receptors, so it is probably a good idea to use the beta-adrenergic before the effect from the last treatment has completely worn off. Does that make any sense?

 

[Aboveallislove]

Thank you so much for all the thoughts. Let me clarify, explain better, and kinda "reask" my question. We have always only done 2 xopenexs a day, before hyper sal and in am. also pulmozyme and qvar. He uses the spacer for the qvar. I started thinking about it and thought "odes xopenex prevent inflammation? why not add a third one that we just do with the inhaler in the middle of the day. It is next to no time in added treatment burden and if I use the inhaler I don't have an extra cup to sterilize. Then I thought darn do I need an extra spacer and wash it too (So question: can you use the Qvar spacer with the Xopenex later)? Our doctor has not asked us to do a third treatment. The few times I have I have nebbed it, but that would not be something I'd want to add prophylactically given the time for him and the time for me with everything else. Of course I'd do and do do when I think there's a need (that isn't preventative.) So then I thought, if it is prophylactic and he hasn't done for 6 years, why wouldn't even 50% of the extra that he could get without the spacer be a good thing AND would get him use to doing it without a spacer. (How old before they stop using the spacer?) So, I'd love to see the studies to know the difference to see if he is getting 50-60% of the meds or only 20%. And any time I thought it was a "need" as oppose to preventative extra, I'd do nebbed anyway. But if it makes the side effects worse or there is another thing that doing from the inhaler does, then obviously I'd want to do the spacer (praying you don't need 2!). This is all me thinking through and getting input before discussing with the doctor. I listen and follow their directions (unless it deals with how to get a kid to eat because they are incompetent and I found my own expert there! ;-), so please know this isn't me trying to override them but to have an intelligent discussion with them.
THANKS!

You do so well with him - what you teach him now will stay with him for the rest of his life - so please, do not stop using the spacer!!! If you want, I can find some of the studies and send to you that quantify the difference in the deposition of the medication with and without the spacer. With proper technique and a spacer, the inhaler can actually be better than the nebulizer! If you decide he does not need the mid-day treatment, just do not give it, but make this decision with the doctor.

Now - back to the original topic - why do bronchodilators for CF. I believe what they told us in RT school was that if you reduce the size of the airway by 1/2, then you increase the resistance to air movement by 16 times! Think about that - that is huge! And think how easy it is to reduce the size of the airway with secretions lining them. So, if you get even minimum effect from the bronchodilator, it is worth it because it is increasing the size of the airways. If your doc wants you to do a mid-day prophylactically (Gosh that's a hard word to spell!), I think I know where he is coming from. Given that CF patients have an abundance of secretions, it's a miracle any bronchodilator ever makes it to the beta-receptors in the lungs (given it is a beta-adrenergic like Albuterol). If the airway is already dilated, you stand a much better chance of the medication getting to the beta-receptors, so it is probably a good idea to use the beta-adrenergic before the effect from the last treatment has completely worn off. Does that make any sense?

 

[The Dot]

Thank you so much for all the thoughts. Let me clarify, explain better, and kinda "reask" my question. We have always only done 2 xopenexs a day, before hyper sal and in am. also pulmozyme and qvar. He uses the spacer for the qvar. I started thinking about it and thought "odes xopenex prevent inflammation? why not add a third one that we just do with the inhaler in the middle of the day. It is next to no time in added treatment burden and if I use the inhaler I don't have an extra cup to sterilize. Then I thought darn do I need an extra spacer and wash it too (So question: can you use the Qvar spacer with the Xopenex later)? Our doctor has not asked us to do a third treatment. The few times I have I have nebbed it, but that would not be something I'd want to add prophylactically given the time for him and the time for me with everything else. Of course I'd do and do do when I think there's a need (that isn't preventative.) So then I thought, if it is prophylactic and he hasn't done for 6 years, why wouldn't even 50% of the extra that he could get without the spacer be a good thing AND would get him use to doing it without a spacer. (How old before they stop using the spacer?) So, I'd love to see the studies to know the difference to see if he is getting 50-60% of the meds or only 20%. And any time I thought it was a "need" as oppose to preventative extra, I'd do nebbed anyway. But if it makes the side effects worse or there is another thing that doing from the inhaler does, then obviously I'd want to do the spacer (praying you don't need 2!). This is all me thinking through and getting input before discussing with the doctor. I listen and follow their directions (unless it deals with how to get a kid to eat because they are incompetent and I found my own expert there! ;-), so please know this isn't me trying to override them but to have an intelligent discussion with them.
THANKS!

Here is a link to an article I was able to find rather quickly. http://www.rcjournal.com/contents/10.05/10.05.1313.pdf
Let me know if you have trouble accessing it and I will send you the PDF via private message. It seems to present the pros and cons of all methods of medication delivery, and even seems to contradict itself at times in doing so. This is a study of many previously performed studies (a meta-analysis). This explains why there are different theories out there, and why different organizations have different standards. Also, there are 41 references at the bottom of the page. If you start digging into these, you will find the statistics you are looking for.

Personally, and this is well-supported by evidence-based research, I believe anyone who is using an inhaler should use a spacer. That said, there are many newer types of inhalers on the market and their makers do not recommend the use of a spacer. The spacer is for traditional MDI (which is no longer available due to PCP being outlawed) or the inhalers with the newer forms of propellant which replaced the MDIs. However, the new Respimat inhaler and similar types of inhalers that spew a spray out of their top will not work with a spacer. DPIs (Dry Powder Inhaler) mentioned in the paper as "not available in the US" are, of course, now available in the US (but weren't when the paper was published) and would not require a spacer. But, with the traditional type of inhaler, the Spacer baffles out the larger particles which tend to land in the upper airways and allows the smaller particles to enter the airways, while allowing for a little bit of timing error if necessary. This is necessary for the inhaler to be as effective as a nebulizer. Therefore, kids do not outgrow spacers, they just grow into a spacer with a mouthpiece instead of a mask. And, yes Virginia, you can use the same spacer for more than one medication . Adults should use spacers as well. Perhaps you can ask your doctor if he knows of a rescue inhaler (like the Respimat, which is mainly prescribed for COPD) that does not require a spacer? Bear in mind, these are difficult for adults to use - lol - but, you know how kids are with child-proof stuff!

 

[Aboveallislove]

Here is a link to an article I was able to find rather quickly. http://www.rcjournal.com/contents/10.05/10.05.1313.pdf
Let me know if you have trouble accessing it and I will send you the PDF via private message. It seems to present the pros and cons of all methods of medication delivery, and even seems to contradict itself at times in doing so. This is a study of many previously performed studies (a meta-analysis). This explains why there are different theories out there, and why different organizations have different standards. Also, there are 41 references at the bottom of the page. If you start digging into these, you will find the statistics you are looking for.

Personally, and this is well-supported by evidence-based research, I believe anyone who is using an inhaler should use a spacer. That said, there are many newer types of inhalers on the market and their makers do not recommend the use of a spacer. The spacer is for traditional MDI (which is no longer available due to PCP being outlawed) or the inhalers with the newer forms of propellant which replaced the MDIs. However, the new Respimat inhaler and similar types of inhalers that spew a spray out of their top will not work with a spacer. DPIs (Dry Powder Inhaler) mentioned in the paper as "not available in the US" are, of course, now available in the US (but weren't when the paper was published) and would not require a spacer. But, with the traditional type of inhaler, the Spacer baffles out the larger particles which tend to land in the upper airways and allows the smaller particles to enter the airways, while allowing for a little bit of timing error if necessary. This is necessary for the inhaler to be as effective as a nebulizer. Therefore, kids do not outgrow spacers, they just grow into a spacer with a mouthpiece instead of a mask. And, yes Virginia, you can use the same spacer for more than one medication . Adults should use spacers as well. Perhaps you can ask your doctor if he knows of a rescue inhaler (like the Respimat, which is mainly prescribed for COPD) that does not require a spacer? Bear in mind, these are difficult for adults to use - lol - but, you know how kids are with child-proof stuff!

thanks dot. Truly appreciate your time and expertise!