Breathing Question

[Guns64D]

Here is a situation for a 18D that comes from an experience i have had in the field.

So no shit there we were. We were in the field for an exercise and I believe it was Hay dust that was all over the place. After a couple of hours in a tent filled with Hay pollen or whatever, I couldn't breath for shit. I would say that about 19 out of 20 people were given albuteral inhalers. That didn't really work for me so I asked the doc for something stronger. He gave me prednisone pills and I was breathing like a champ.

The question is, if you are on a team, down range, would you use this method for a situation like this? I have never had breathing problems, so I believe that at least a couple of guys on an A-detachment could potentially experience a problem like this, and maybe on mission in some podunk village downrange.

Also, since this was a one time occurence, would you document it in your medical file?

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[Guns64D]

To expound:

No sneezing.
Tearing caused by difficulty breathing.
Coughing, yes with a very sharp weeze at the end of the cough.
Time of year was April.
Unit could not be moved.

Most people did not ask for more Meds, but when they were sleeping they sounded like they were gonna die. A lot of coughing and weezing going on.

I forgot to add that I also was given Sudafed. All it did was dry my airways and sinuses up but it did not help with the difficulty breathing.

After we were out of the field, all problems stopped. I am thinking that since we were not from the area, our bodies were not used to the hay (pollen?). The pollen at Bragg doesn't really bother me anymore, but this was Ft. Hood.

Also, it was not an 18D that perscribed me the predisone, it was a physician.

To get to the point, I am amazed at how good Prednisone was in getting me back to 100%. I have read a bunch of these threads and I haven't heard about much use of the drug for emergencies involving respiratory illnesses. I guess you never know when you'll be in a situation like this and maybe this a topic in this thread will help out...or not.

What are your thoughts? Thanks for help.

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[Patriot007]

Just a student here with a question to add to the discussion. It seems to me one of the major factors that would make taking Prednisone not ideal in said conditions is that it is immunosuppressive. Shutting down one's immune system on a prolonged austere operation doesn't sound ideal to me. Thoughts?

[shr7]

Prednisone is commonly used for short term control of allergic asthma. It is a very dangerous drug to be used long term, and is not the safest to use short term either. Our patients are given an asthma action plan (hopefully). First resort, they hit themselves with Albuterol. Second resort, more Albuterol. Last resort, more Albuterol, then we start them on a SHORT course of prednisone. Do not worry about the immunosuppresive effects if it is only a short course of the drug. Maybe start to think about it after 4 weeks. However, if you are taking it for more than a couple weeks anyway, you have got a boatload of issues to deal with, that could fill up this entire thread.

There are medications you can take to preempt these symptoms when you know you are going to be in a situation like this. I would be out of my lane to suggest them, since I don't know what kind of drugs are available to you out in the field, or if you would be able to receive them before a field exercise. But, if you run across this problem in your personal life, inhaled steroids (like Flovent), leukotriene inhibitors (like Singulair) and mast cell stabilizers (like Cromolyn) can all have benefit. But again, I don't know what the situation is in the armed forces as far as access to these drugs.

But in reference to your original questions,
1) I don't know, the medics out there may have an answer.
2) I would document it.

EDIT: I forgot to add, RF 1 is all too correct when he states that the inhaler needs to be used properly. Giving a bunch of people inhalers that have never used them before, you are almost guaranteed to get some weird stuff going on. Where to place them, number of puffs, how long between each puff, number of puffs per day, how often to take your dose. It is not nearly as easy as it seems.

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[shr7]

Oh yeah, I forgot the easy answer. Antihistamines. RF 1 asked if they were tried? Also, those would be available to those in the field. Good if you know your going to be in pollen rich conditions. I would steer with the newer non-drowsy medications (Claritin) if you are going to be operating heavy machinery or heavy weapons. Sorry for the omission.

[Patriot007]

Patriot,

Pretty sure a single dose of Prednisone in the field will have more positive effects than negative in the presented setting.

RF 1

Noted. I was thinking more on regular dosages in the event of prolonged exposure to respiratory irritants e.g. the hay dust, Thanks for the reply Doc.

[sofmed]

Patriot,

Cortocosteroids do not appear to inhibit antibody production to any great extent in : Monkeys, Guinea Pigs or Man..... Mice, Rats and Rabbits do, under some conditions, show some inhibition.

Pretty sure a single dose of Prednisone in the field will have more positive effects than negative in the presented setting.

Agree with shr7, Albuterol, Albuterol, Albuterol.

RF 1


Just remember, gents, that the Albuterol WILL cause your pt to become tachy, especially two and three doses in, and that, coupled with any underlying issues can complicate matters: mitral valve prolapse, undiagnosed; any CVA's such as bi and tri-geminy's diagnosed or not, already elevated BP, not to mention interactions with other meds the pt may be currently taking. So get a complete history from your pt before you allow him to start puffing away.

And think...location, location, location. Can you get the pt away from the immediate area to see if the breathing issue clears up over a specified time on its own. If this is the case, then the issue is one of location and meds are not necessarily needed.

Just my .02.

Cheers!

Mick

[shr7]

sofmed-
I will be the first to tell you you have worlds more experience than me. In fact, you probably have over 3x as much experience in the FIELD, than I even have in the classroom. So, anything I say here, when push comes to shove, I am hoping to learn from you, anything I can offer to you is just gravy.

I agree with the location, location, location, but in his second post, he states the unit could not be moved, I think that is why we didn't really bother discussing it. I think his original question was more of, in this situation, if the team could not be moved, what would the medic do?

Albuterol is a potent B2 agonist, causing relaxation of the bronchial smooth muscle. The side effects are caused by B1 agonism in the CV system, because even our more "selective" agents aren't completely selective. You probably are already aware of this, but hey, its not a private conversation so we'll get everyone on the same page. B1 receptors are affected by a whole range of chemicals, both exogenous and endogenous. If you've ever hit yourself or someone else in acute anaphylaxis with epinephrine just watch the HR and BP. Albuterol is chemically almost identical to epinephrine, it just has a very polar ionizing group on it to prevent it from moving into the blood from the bronchii.

My point? If the patient cannot tolerate Albuterol due to the SE profile, they have no business in the field in the Army. At any moment if you get spooked, scared, surprised, excited, or any other activation of the sympathetic nervous system, the resulting catecholamine release will activate the same receptors as Albuterol. I don't think we want people in the field that will clutch their chest and drop to the ground when the lead starts flying. Good point, that these conditions may be undiagnosed. I would agree medication is always the last option, even if its bad for my business. But in the presented situation, it seems like the best.

If my patient is having difficulty breathing, Albuterol is OFTEN the safest and most effective measure. (Unless you buy the crap that those Xopenex people lay down.)

You would be a great person to comment on the original question as to what medications are available in the field, say far removed from clinics/pharmacies. Do medics carry Albuterol? Prednisone? Would they try an antihistamine first? If the unit could not be moved, and you determined your team was healthy as a collective group of oxen, what could be done? Maybe as simple as covering your mouth and nose with a mask/scarf?

[sofmed]

Maybe as simple as covering your mouth and nose with a mask/scarf?

Was thinking that, but it seemed so preposterously simple, I refrained from doing so.

Also, in my diverse clinical experience I have seen men who were otherwise healthy as oxen begin to present with abnormal s/s due to various environmental stimulations, whether it be from elevated physical output, pollen,...whatever you can think of...wind up being sent to the hospital with either severe palpatations (which later was diagnosed as CVA/Tri-geminy and was cleared only by a cardiologist), bronchiospasms causing dizziness and syncope, and sudden onset anaphylxis from unknown etiology, etc. so I'm just trying to cover every option of which I can think.

I do appreciate the discussion as to the chemical based relations of the antagonist to the pt on a cellular level, as well as the intervention of properly administered medications in order to either reverse or temporarily halt said chemical reaction(s).

Also, remember that many soldiers develop various medical 'problems' throughout their career, just as civilians do as they grow older...we're not immune to our genetic make-up or the things around us any more than anyone else, so I can say that I know several soldiers on Atenolol, Lisinopril, HCTZ, Flomax and even Glyburide and Metformin. As long as they can continue to function regarding their daily duties they're good to go. They are simply monitored more closely by their MD's than other soldiers, and if the condition becomes more problematic they will face a medical board to determine their retention worthiness.

As for the medications carried in the field...It depends on the competence of the medic and the trust level the PA or MD has in said medic.

I personally carry Proventil, Albuterol, Allegra-D tabs, Benadryl injectibles, epi-pen x2, Toradol, Glucagon pen, Phenergan for nausea or sedation, just as starters for the more serious oriented issues. We're limited by space because in the field we're more likely to see some kind of trauma than anything else, but other issues do arise.

Not to make light, but we're all one big chemistry set and anything can set us off at any time.

Thanks for all the input. Great thread! Keep it going. I actually learned some things today. :)

Cheers!

Mick

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[shr7]

sofmed-

Thank you for the thoughtful and thorough reply. Very interesting stuff. What is most interesting to me is about the diabetic/soldier. I never thought about diabetics in the military. It is also very interesting to me about the medications that you carry. Seeing how prepared you are for events other than the trauma injury.

As for the chemistry, I knew there was a reason we had to memorize all of those structures. It is actually incredibly interesting to see how the chemistry of the molecule relates to its function. SAR (structure-activity relationship) is an acronym that is pounded into our heads from day one.

Thank you again for the reply, one of the main reasons I joined this board was to get an Army twist on pharmacy in the field. I'll tear myself away from the keyboard now though, I could talk drugs all day, and that wouldn't be good for anybody. Hope to cross paths again in the future. :)

Steve

[Guns64D]

Thanks a ton for the replies. I have learned a whole lot from this thread.

I consider myself exceptionally healthy. This was an experience that kind of scared me.... Should I go to Ranger school, SFAS, etc. not knowing if I am medically fit for something in the dark side. I'll go and document this....just in case something happens in the future.

I guess sometimes we think of ourselves as having above average health, and something like this humbles yourself. Luckily this was over two years ago and I have had no problems since so I'll keep all options on the table.

Thanks again.