Respiratory Therapy 101: Just Keep Breathing

Ativan is one of my favorite drugs for patients to be taking. A wonderfully potent anxiolytic, it generally has a mellowing effect on jittery or nervous patients. Simply popping an Ativan pill or shooting someone up with the IV form of this drug can make interactions with anxious or agitated patients much, much better–unless it makes it worse*, but that’s a whole different post.

One area in which I feel Ativan is vastly underused is the respiratory care arena. Nebulized Ativan is something I have long advocated for, and it is an idea whose time has come. Here is why.

Nebulizer therapy is often ordered by caregivers for reasons that are not related to nebulizer therapy. Physicians have a habit of ordering nebulizers on patients for reasons that are unclear at best or outrageous at worst: for example, doctors who order Albuterol nebulizers on postoperative bunionectomy patients with no relevant history, or who order albuterol nebulizers to treat congestive heart failure.

Physicians are not the only guilty group. Nurses who hear “wet” lung sounds often insist that albuterol, a bronchodilator, will cure their patient of a non-bronchospastic condition such as pneumonia or CHF. Sometimes, nurses will insist that nebulizers be given to patients because “they have a history,” whether or not the patient is symptomatic at the present moment–this would be fine if they were asking us to deliver control medicine such as a long-acting beta agonist or an inhaled steroid, but almost always they are asking us to give rescue drugs that have no preventive effect to patients who are not in need of rescue. This drives me insane.

Nurses and physicians both often ask for nebulizer treatments simply because they have run out of other ideas and it makes them feel better. The psychological effect on the patient and the caregivers of “seeing” that something (such as a nebulizer) is being done is enormous, and I suspect that a great many nebulizers that are given in semi-emergent situations are given because people are out of ideas and want to feel that they are doing something concrete or visible.

Ativan nebulizers can solve all of these problems.

First, physicians who order nebulizers because they are out of ideas. Ativan has a broader spectrum of use than albuterol. Arguably, any patient who comes into the hospital could be given Ativan, since the experience of being hospitalized or treated as an outpatient is likely to generate anxiety. Now, physicians as a collective are not usually receptive to new ideas, so I have no hope of getting the ones who abuse nebulizers to stop doing so: but maybe I can make them do it in a way less harmful to the patient. If we could convince these nebulizer-loving MDs that Ativan–not Albuterol– was the new miracle drug, then we could successfully prevent patient anxiety and the anxiety of anybody within about two feet of the nebulizer.

As far as hypersensitive RNs** who believe that nebulizers will cure all of the ills of their patients from toe fungus to brain tumors, we can see once more the utility of Ativan nebulizers. By asking the nurse to administer the ativan nebulizer to the patient, we can be assured that simply due to the close proximity of the nurse to the anxiolytic mist, our “nuisance calls***” will drop by an enormous percentage–and that lucky patient will be able to relax and maybe even get some sleep in the bustling din of the hospital.

Finally we come to the nebulizers that are ordered just to make people feel better. Since this is the desire at the root of a large chunk of ordered nebulizers, putting Ativan into the neb cup and letting everyone inhale that delicious mist would actually meet the secret objective here. Physicians who just like to order nebs will actually feel better and maybe relax; nurses who want to feel like they are doing something more will be filled with sensations of joy and wonder; and patients will benefit enormously from the sudden drop in worries and the attention given to them by people hoping to get a little breath of fresh air out the end of the corrugated tubing.

Ativan nebs: their time has come.

*Ativan can cause confusion and delerium. Certain patients, especially in my experience elderly patients, will become confused and agitated by the administration of Ativan.

**Not all nurses fall into this category. I’ve been lucky enough to work with plenty of nurses who understand the relatively limited role of the nebulizer in patient care, but I have also been plagued by nurses who believe that Albuterol will raise the dead.

***A large percentage of the calls that I have personally gotten from floor nurses have been nothing more than nuisances. Many calls are genuine, but many more are simply because they believe that the Almighty Nebulizer Will Raise The Dead.