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MCHD emergency protocol to eliminate nebulized albuterol

Montgomery County Hospital District EMS is using a low-cost approach to administer albuterol via metered-dose inhaler, reducing viral spread without compromising patient care


0.5% Albuterol Sulfate preparation, vial with eyedropper for inhalation by nebulizer Image: Intropin/Wikimedia Commons

The COVID-19 pandemic has forced EMS and all emergency providers to reassess our approach to airway management and treatment. This is especially true when we must care for patients with cough, fever and difficulty breathing prior to knowing their infectious status.

Coronaviruses are transmitted via patient droplets. However, prehospital providers can increase the risk of viral transmission by aerosolizing patient droplets. This is thought to occur in several situations, such as suctioning, intubation, utilizing a BVM, during non-invasive positive pressure ventilation, with high-flow oxygen use (>6L/min), or when administering nebulized medications.

At Montgomery County Hospital District EMS in Greater Houston, a low-cost approach is being used to create a spacer which will allow patients to receive albuterol via metered-dose inhaler (MDI) as opposed to in the usual nebulized form.

Even if your service cannot rapidly source or afford MDI albuterol, another option would be to allow medics to give the patient their own albuterol during transport, if they have a prescription MDI available.

This approach will decrease viral spread without compromising patient care. In fact, in one large prospective ED study, MDI albuterol demonstrated decreased length of stay, increased oxygen saturation and decreased ED return visits when compared to nebulized albuterol [1].

How to administer MDI albuterol with a spacer

Take a look at the following video that demonstrates a simple and safe method to administer MDI albuterol with a spacer allowing for maximal beta-agonist effect.

COVID-19 update

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  1. Newman KB, et al. A comparison of albuterol administered by MDI and spacer with albuterol by nebulizer in adults presenting to an urban ED with acute asthma. Chest. April 2002;121:1036–41.

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The MCHD Paramedic Podcast was launched in early 2018 in an effort to provide easily consumable core-content EMS education and insights from prehospital care thought leaders. The Clinical Services Department of The Montgomery County Hospital District EMS service developed the podcast as a tool to better engage and disseminate continuing education to our MCHD medics as well as first responders and EMS professionals nationwide.

Dr. Casey Patrick is the assistant medical director for Montgomery County Hospital District EMS and is a practicing emergency physician in multiple community emergency departments across Greater Houston. His EMS educational focus is on innovative paramedic teaching via the MCHD Paramedic Podcast. Dr. Patrick’s prehospital clinical research involves the investigation of paramedic use of bolus dose intravenous nitroglycerin for acute pulmonary edema and the implementation of lung protective ventilation strategies for intubated EMS patients. Casey and his wife, Alyssa, work and live in Conroe, Texas, and Spokane, Washington. Together they have five children: Mia, Ainsley, Brock, Dean and Will.

Dr. Dickson graduated with honors from the University of Texas Health Science Center San Antonio in 2001 and completed emergency medicine training at Indiana University in 2004. He serves as the EMS medical director at Montgomery County Hospital District EMS and an assistant professor of emergency medicine at Baylor College of Medicine in Houston, Texas. His academic interests include systems of care in stroke and other time-sensitive emergencies, neurologic emergencies and education. He is board certified in emergency medicine in both the U.S. and Australasia, and has subspecialty board certification in EMS medicine. He has authored multiple professional articles and presented at regional, national and international conferences on emergency medicine and EMS topics.