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BLS Treatment of Asthma

Using Albuterol Sulfate

Aaron J. Katz, AEMT-P, CICwww.es26medic.com

www.prehospitaltraining.com

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Some Typical Scenarios

• 6 yo severe respiratory distress. History of asthma. 50 breaths per minute. No wheezing heard.

• 68 yo. History of 4 MIs, CABG X 4, APE, NIDD. Tripoding, wheezing. 32 breaths per minute.

• 40 yo in respiratory distress. History of asthma. Took “asthma spray” 10 times in 5 minutes. Started getting better, now getting worse. 30 breaths per minute.

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IntroductionIntroduction

• In 1996, asthma was the leading cause of hospitalizations in New York City for children (up to the age of 14 ).

• In 1995, asthma hospitalizations for children of the same age group were 3 times the national average and 5 times the state average.

• In 1996, asthma was the leading cause of hospitalizations in New York City for children (up to the age of 14 ).

• In 1995, asthma hospitalizations for children of the same age group were 3 times the national average and 5 times the state average.

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Introduction (cont.)Introduction (cont.)

• In New York City, EMTs & Paramedics treat approximately 50,000 asthmatics each year.

• While these patients benefit from bronchodilator therapy, the availability of ALS response units cannot always be assured.

• As a result, these patients are treated by EMTs.

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Mortality from asthma is increasing worldwide

From 1980 - 1987, the death rate From 1980 - 1987, the death rate has increased by 31% in the United has increased by 31% in the United

States. 5,000 deaths per year.States. 5,000 deaths per year.

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Many studies have shown

The efficacy and SAFETY of albuterol in the treatment of bronchospasm associated with asthma.

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An expanded scope of practice for EMTs

Could provide benefits to the population of asthmatics in New

York City

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Inclusion CriteriaInclusion Criteria

• Patients between the ages of 1 and 65 years old (with no ALS immediately available).

• Patients complaining of difficulty breathing secondary to an exacerbation of their previously diagnosed asthma.

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Exclusion CriteriaExclusion Criteria

• Patients with a history of hypersensitivity to albuterol sulfate.

• Patients exhibiting signs of respiratory failure (a patient requiring ventilations).

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Adult Respiratory Failure

• Decreased level of consciousness

• Too dyspneic to speak

• Cyanosis (despite oxygen therapy)

• Diminished breath sounds

• Patient requires assisted ventilations

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Pediatric Respiratory Failure

• Ineffective respiratory effort with• Central cyanosis• Agitation or lethargy• Severe dyspnea• Labored breathing• Bobbing or grunting • Marked intercostal & parasternal retractions.

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Differential Diagnosis of Bronchospasm

• COPD

• Foreign body obstruction

• Pulmonary Embolus

• Anaphylactic reaction

• Pulmonary Edema

• Asthma

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Pathology of Asthma

• Reversible smooth muscle spasm of the airway associated with hypersensitivity of the airway to different stimuli. Primarily an inflammatory process.

• Smooth muscle contractions

• Mucosal edema

• Mucous plugging

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The Lungs

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The Lower Airway

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Triggers of Asthma Attacks

• Allergies

• Infection

• Stress

• Temperature changes

• Seasonal changes

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Signs and Symptoms

• Dyspnea• Wheezing• Tachypnea• Tachycardia• Cyanosis• Cough

• Accessory muscle use• Inability to speak…..

in complete… sentences.• Anxiety (hypoxia)• Prolonged expiratory phase• Tripod positioning• Nasal Flaring (infants)

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Respiratory Muscle Fatigue

• Muscles are overworked to compensate for problem.

• Increased work of breathing

• Can lead to exhaustion and respiratory failure.

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Assessment of The Asthma Patient

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Assessment of the Asthmatic

• Chief complaint

• History of present illness

• Past medical history

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History of Present Illness

• How long

• Events leading up to…

• How severe (Borg Scale)

• Aggravating / Alleviating factors

• Other complaints

• Steroid use in last 24 hours (p.o. / inhaled)

• Other medications

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Past Medical History

• Confirm asthma history

• Other medical conditions (cardiac)

• E.D. visits for asthma in the last 12 months

• Hospital admissions for asthma in last 12 months

• Previously intubated due to asthma?

• Allergies to medications, etc.

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Note: Do not delay treatment to solicit a patient’s medical history

(except: asthma,allergies and cardiac history.)

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Physical Examination

• Respiratory distress vs. Respiratory failure• Posturing (tripod positioning)• Pursed lip breathing• Vital signs• Skin color, temperature and moisture• Ability to speak... in complete... sentences• Accessory muscle use• Borg Score (0 to 10)

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Auscultation of Breath Sounds

• General requirements for successful evaluation:

• Patience

• Effective technique

• Good hearing

• Knowledge of sounds

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Physical Examination (cont.)

• Assessing lung sounds• Rales

• Rhonchi

• Stridor

• Wheezing

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Lung Sounds Found In Common Emergency Conditions

• C.O.P.D.– Diminished– Wheezes– Prolonged expiratory phase

• Pneumonia– Rales (usually in one area)

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Lung Sounds Found In Common Emergency Conditions

• Pulmonary Edema– Diminished Sounds– Rales (usually bilateral and on inspiration)

• Asthma– Diminished Sounds (may be on one side)– Wheezes– Prolonged expiratory phase

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Wheezes

• High pitched, continuous sounds

• Occur on inspiration or expiration

• Result of narrowed bronchioles

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Wheezing Assessment

• No Wheezing

• Wheezing (audible with stethoscope)

• Wheezing (audible without scope)

• Poor air exchange (diminished lung sounds)

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Absent or Diminished Sounds

• Pneumothorax

• Hemothorax

• Obesity

• Hypoventilation

• Fluid or pus in pleura or lung

• COPD or Asthma with poor airflow

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Stethoscope Placement

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Technique

• Sit patient up

• May not be possible to auscultate all areas

• Place diaphragm firmly on chest wall

• Avoid extraneous noise

• Avoid prolonged examination of the chest

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Technique

• Have the patient open mouth and take deep breaths.

• Avoid hyperventilation.

• Listen at each location and note abnormalities.

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Albuterol Sulfate Ampules

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Pharmacology: Albuterol Sulfate• Actions

– Bronchodilator

• Minimal side effects• Nervousness • Palpitations

• Dizziness • Drowsiness

• Flushing • Chest discomfort

• Tachycardia • Muscle cramps

• Dry mouth • Insomnia

• Tremors • Weakness

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Indications for Use

• Relief of bronchospasm due to exacerbation of asthma.

Use with caution for patients with:• Previous M.I.

• C.H.F. You must contact

• Angina Medical Control

• Arrhythmias

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Contraindications

• Patients with known hypersensitivity to the medication or its components.

• Patients in respiratory failure(those patients requiring ventilatory assistance)

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Dosage

• One unit dose, 3.0 cc or 0.083%

Via nebulizer at 6 liters per minute or at a flow rate that will deliver the

medication over 5 to 15 minutes.

• Dose may be repeated if the symptoms persist for a total of 2 doses.

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5 rights of Medication Administration

• Right Patient

• Right Drug (beware look alikes)

• Right Dosage

• Right Route

• Right Time

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Check 3 Times For:

• Expiration Date

• Discoloration and Clarity

• Particulate matter

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Administration (cont.)

• Assemble nebulizer

• Add medication

• Attach to oxygen regulator

• Set flow meter to 6 lpm

• Instruct patient on use– inform adult patient– modify delivery for very young patients

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Nebulizer

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Assembled Nebulizer

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Assembled Nebulizer and Oxygen Tubing

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Treatment of Asthma Patient

• Assess breathing

• Administer oxygen via non - rebreather

or assist ventilations

• Monitor Breathing

• Do not permit physical activity

• Place patient in position of comfort

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Assess and Document prior to administration of albuterol

• Patient is between 1 and 65 years of age

• Dyspnea is secondary to previously diagnosed asthma

• Vital signs

• Ability to speak… in complete... sentences

• Accessory muscle use

• Wheezing assessment

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Assess and Document prior to administration of albuterol (cont.)

• Borg scale (0 - 10)

• Contact medical control if patient has pertinent cardiac history

• “The 5 rights” of medication administration

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Treatment (cont.)

• Administer albuterol sulfate (one unit dose) via nebulizer (6 lpm)

• Begin transport– Do not delay transport to administer medication

• If symptoms persist, give 2nd dose

• Upon transfer of patient, reassess and document as before.

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Treatment (cont.)

• Medical control MUST be contacted for any patient who refuses medical assistance or transport.

• Request ALS – Especially, if the patient is in danger of going

into respiratory failure

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Scenarios – let’s treat them!

• 6 yo severe respiratory distress. History of asthma. 50 breaths per minute. No wheezing heard.

• 68 yo. History of 4 MIs, CABG X 4, APE, NIDD. Tripoding, wheezing. 32 breaths per minute.

• 40 yo in respiratory distress. History of asthma. Took “asthma spray” 10 times in 5 minutes. Started getting better, now getting worse. 30 breaths per minute.

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Questions?