Wednesday, March 30, 2016

1930s-1990s?: Alcohol aerosolization for pulmonary edema

Although I have never seen it, I am aware that alcohol was once used as a treatment for foaming pulmonary edema. It was nebulized as a breathing treatment, forced into the airway by IPPB, or inserted into the ETT. I have heard stories of Vodka being used, although Ethanol Alcohol (ETOH) may also have been an option.

The most common cause of foaming pulmonary edema is heart failure. The dyspnea felt is usually so bad that it causes orthopnea, meaning that the person has to sit up to breathe. Usually the patient has a feeling of impending doom, and will cry out for help. That's my experience with it anyway.

So, what is it? For most of history it was diagnosed as asthma. However, after William Harvey convinced the medical community that blood circulates through the body, this inspired Raymond Vieussens to study the heart. He became the first physician to describe dyspnea caused by a failing heart as separate from dyspnea caused by the lungs. This was during the 1670s.

In 1669, Giorgio Baglivi was the first to describe pulmonary edema (or at least that's what he appeared to describe). He referred to it as "suffocative catarrh."

In 1830 Dr. James Hope was a cardiologist who wrote a book called "A treaties on the diseases of the heart and great vessels."  In it he described how an overworked heart becomes enlarged, as any overworked muscle would.  When this happens it becomes a weak heart. When it poops out it becomes too weak to pump blood through the heart and lungs, and this causes blood to become backed up (congested) all the way back to the capillaries in the lungs, where it seeps out, thus causing pulmonary edema.

Now we know it's a little more than that, and can be caused by other things too, such as fluid overload and kidney failure. It is more likely to occur in the elderly and the sick more so than in the young, although I have seen it in a 26-years-old female.

As blood seeps into the lungs it increases the pulmonary vascular resistance, otherwise known as the blood pressure in the lungs. As this happens, blood will seep out of the blood vessels and into the lungs, causing increased fluid build up in the lungs called pulmonary edema. It's referred as foaming pulmonary edema because it is pink and frothy. This is because it is a mixture of airway secretions and blood.

This results in severe dyspnea and orthopnea. It means that immediate medical treatment is necessary or the person will probably die. It can result from a disease like heart failure or kidney failure, although it may also may be caused when a person is given too much fluid. It can happen slowly over time, and when this happens it may also cause fluid to build up in the lower legs and ankles. It can also happen in a short period of time, and in this case it's often referred to as flash pulmonary edema.

This would explain why some ancient physicians found that diuretics worked to treat asthma. This was because diuretics cause fluid to be drained from the body, from the lungs, from the legs, etc. It caused the person to pee. The more a person pees the more relief will be felt. Today the most common diuretics are Lasix and Bumex. These are given through the IV, and usually work pretty fast.

In the past, however, when there was no effective treatment, the patient's lungs would become so full of foaming pulmonary edema that it would start to come out of the patients mouth and nose. I saw this happen on my first day as a respiratory therapist, and the patient refused treatment, and was dead within five minutes. So it's an impending emergency.

Back in the 1930s, there were no truly effective diuretics, and it was known that Vodka seemed to sooth the foam. So it was often given to these patients. It seemed to stabilize the foaming bubbles which results in rapid dispersion of the bubbles. (1, page 417)

I have been told that it worked really well. In some cases it calmed the foaming bubbles right down and made breathing easier. The theory was it reduced surface tension of the fluid to reduce resistance in the alveoli. This made breathing easier.

I'm told Vodka was used. One therapist told me the pharmacist would sometimes have to make trips to the store to get Vodka. The 1991 edition of "Respiratory Care: A Guide to Clinical Practice," said the dose was 3-5ml of 30-50% ethanol alcohol.  (2, page 417)

Apparently, studies performed in the late 40s or early 50s showed it to be both effective and safe. It was discussed in the 1950 edition of the New England Journal of Medicine (Gootnick, et al).
Inhalation of certain volatile substances decreases the amount of foam in the respiratory passages and may be helpful in acute pulmonary edema. Experiments with several agents were performed in animals with different types of acute edema of the lungs. The best results were obtained with ethyl alcohol, which decreased the severity of the edema and prolonged the survival of the animals. Alcohol, while acting as an antifoaming agent, has no untoward side effects and is well tolerated. This method of therapy is now undergoing clinical tests. (3)
It was also discussed in a 1952 edition of Circulation (Aldo, et al). The authors reviewed a study where alcohol was given by aerosol or with pressure therapy (probably IPPB). They list some of the other options for treating foaming pulmonary edema of various causes. These include:

  • Morphine
  • Phenobarbital
  • Oxygen
  • Positive Pressure
  • Venesection 
Some patients already received an initial dose of medicine by rescue crews prior to being admitted to the hospital, the authors note. They said, "If, a suitable interval having elapsed, the attack continued unabated in spite of the above procedures, then alcohol inhalation was started. This plan was adopted in order to avoid the objection that life-saving procedures and drug therapy had been omitted to the possible detriment of the patients. (4, page 368)

I really don't know when it was stopped. I learned about it when I was a respiratory student in 1995, so chances are it was long phased out by then. It 4was probably phased out during the 1960s and 70s after the diuretic furosimide (Lasix) was introduced to the market and discovered to be both safe and effective.

I have seen some discussions among healthcare communities where it has been theorized alcohol inhalations were stopped due to harsh side effects. One nurse stated that, since the alcohol was delivered directly into the blood stream through the lungs, it would have resulted in a good drunk, followed by a nasty hangover the next day.

However, Gootnick et all notes that this is not true. Among all the patients who participated in the experiments, "The concentration of alcohol detected in the blood was small; it's general effects were negligible." (4, page 364)

If you have stories about alcohol aerosols or droplets used to treat foaming pulmonary edema, please share in the comments below. If I learn more I will be sure to do the same.
References:
  1. Burton, George G, John Elliot Hodgkin, Jeffrey J. Ward, "Respiratory Care: a guide to clinical practice," 1991, Lippincott
  2. Lough, Marvin D., Robert L. Chatburn, W. Arlen Schrock, "Handbook of Respiratory Care," 1983, Year Book Medical Publishers
  3. Gootnick, Abraham, Henry I Lipson, Joseph Turbin, " "Inhalation of ethyl alcohol for pulmonary edema." New England Journal of Medicine, November 29, 1951, 245: 842-843
  4. Aldo, et al, "Alcohol Vapor by Inhalation in the Treatment of Acute Pulmonary Edema," Circulation, 1952, Volume 5, pages 363-369

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