EBM Consult

Inhaled isopropyl alcohol for the treatment of nausea and vomiting

PICOTS:

  • P = Patients presenting with a chief complaint of nausea or vomiting
  • I  = Inhaled isopropyl alcohol (IPA)
  • C = Oral ondansetron and inhaled normal saline (INS)
  • O = Improved visual analog scores for nausea and vomiting
  • T = Acute setting (10 min to 30 min) 
  • S = Emergency Department


Note: PICOTS stands for (P) for patient, (I) for intervention of interest, (C) for comparison, (O) for outcome of interest, (T) for timing, & (S) for setting.


Take Home Point(s):

  • Inhaled isopropyl alcohol (IPA) offers a rapid onset of relief for diverse patients presenting to the ED for nausea and vomiting.
  • IPA has been shown to be more effective in treating Emergency Department (ED) patients with nausea and vomiting than oral ondansetron alone.
  • Larger studies comparing inhaled IPA to other anti-emetics need to be done, along with exploring its effectiveness in pediatric and palliative populations.
  • IPA offers a cost-effective, readily available, and effective alternative for treating patients presenting to the Emergency Department with nausea and vomiting.
  • To our knowledge, there are no formal guidelines or position statements published that recommend IPA for the treatment of nausea and vomiting for patients in the emergency department or other clinical settings. There was one Cochrane Review that did look at the use of IPA, but it was in the context of post-operative nausea and vomiting vs. the ED.


Summary:

Nausea and vomiting is one of the most common chief complaints in Emergency Departments (ED). There are numerous different anti-emetics utilized by emergency medicine providers to provide relief; however, randomized clinical trials have not yet demonstrated a medication, whether given orally or intravenously, that is superior to others. Inhaled Isopropyl Alcohol (IPA) is a cheap, readily available, and relatively safe alternative for treating nausea and vomiting in the ED. IPA has been shown to provide rapid relief and improvement in patient symptoms while also increasing patient satisfaction. IPA has also been shown to provide increased relief of patients with nausea and vomiting compared to oral ondansetron. Future research is needed regarding comparative effectiveness of IPA and other anti-emetics, as well as future research in pediatric populations.
 

Author:  Kristofer Montoya, MD - (Johns Hopkins School of Medicine)

Editor: Philip Magidson, MD - (Johns Hopkins School of Medicine) and Joshua Niforatos, MD - (Johns Hopkins School of Medicine)

Editor-in-Chief:  Anthony J. Busti, MD, PharmD, MSc, FNLA, FAHA 

Date Last Reviewed:  January 2023

Guideline Statements

  • Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting.

    • There are no formal recommendations about the use of inhaled isopropyl alcohol (IPA) for the treatment of nausea and vomiting even for this clinical setting (i.e., post-operative nausea and vomting; PONV).
    • However, this guideline does comment on the Cochrane Review by Hines et al, 2018 which evaluated various agents in aromatherapy (including IPA) in the context of the post-operative setting indicating that IPA, "resulted in shorter time to 50% reduction in nausea severity, less need for rescue antiemetics, but no difference in patient satisfaction.  On the other hand, isopropyl alcohol vapor inhalation, did not reduce the need for rescue antiemetics (evidence A1)." p. 425
  • 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer patients.

    • There is no mention of inhaled treatment options or aromatherapy for patients regardless of the clinical practice setting they are presenting to within the healthcare system for care.
    • Since oncology patients receiving radiation and chemotherapy will commonly present to the ED while be managed for their cancer, this guideline was given consideration in this review.
  • Antiemetics: ASCO Guideline Update.

    • There is no mention of inhaled treatment options or aromatherapy for patients regardless of the clinical practice setting they are presenting to within the healthcare system for care.
    • Since oncology patients receiving treatment will commonly present to the ED while be managed for their cancer, this guideline was given consideration in this review.

Cochrane Reviews

  • Furyk JS, et al.  Drugs for the treatment of nausea and vomiting in adults in the emergency department setting.  Cochrane Database Syst Review 2015;Sep 28(9):CD010106.  Cochrane Library

    • While there are many different antiemetic medications evaluated in this Cochrane Review of evidence from studies considered to be of “low quality”, the authors did not find any convincing evidence that one medication was superior to other active controls or even placebo. 
    • Note: This review did not include inhaled treatment options or aromatherapy.  Thus, this review did not address inhaled isopropyl alcohol as a treatment option for patients with nausea and vomiting in the ED.
  • Hines S et al.  Aromatherapy for treatment of postoperative nausea and vomiting. 2018;(3):CD007598  Cochrane Library

    • While this Cochrane review was only in the post-operative setting (and not specifically applicable to the specific PICOTS for this EBM article), this review did report that inhaled isopropyl alcohol (IPA) resulted in shorter time to 50% reduction in nausea severity, less need for rescue antiemetics, but no difference in patient satisfaction.  Furthermore, isopropyl alcohol vapor inhalation did not reduce the need for rescue antiemetics.
    • At the same time, IPA was not harmful and easy to implement in most clinical settings.

Systematic Reviews/Meta-Analysis (Non-Cochrane Reviews)

  • Meltzer AC and Mazer-Amirshahi M.  For Adults With Nausea and Vomiting in the Emergency Department, What Medications Provide Rapid Relief?  Ann Emerg Med 2016;68(6):717-718.  PubMed

    • This publication is technically not a sysmetatic review, but a summary of a portion of another Cochrane review (per the publication). 
    • Note: This paper (nor the original Cochrane Review) did not include inhaled treatment options or aromatherapy.  Thus, this report did address inhaled isopropyl alcohol as a treatment option for patients with nausea and vomiting in the ED.

Original Studies

  • April MD, Oliver JJ, Davis WT, Ong D, Simon EM, Ng PC, Hunter CJ. Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial. Ann Emerg Med. 2018 Aug;72(2):184-193.  PubMed

  • Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2016 Jul;68(1):1-9.e1. PubMed

  • Candemir H, Akoglu H, Sanri E, Onur O, Denizbasi A. Isopropyl alcohol nasal inhalation for nausea in the triage of an adult emergency department. Am J Emerg Med. 2021 Mar;41:9-13.  PubMed

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