# 8 y/o Severe brochospasm scenario



## mc400 (Dec 20, 2010)

Hey fella's just wanted to run a scenario I faced yesterday.

Dispatch info: 8 year old Female. Resp distress since last night, several albuterol treatments with no relief. 

U/A Pt sitting on a couch surrounded by family members. 
Pt in tripod position with obvious distress and working hard to breathe.
Pt on albuterol SVN supplied by room air nebulizer.
Wheezes only heard through stethoscope, 32 resp/min lungs sound coarse and very tight. Pt appears very tired and family states she has had 5-6 treatments throughout the night and it is now 1000hrs.

We followed protocol which for us is only combivent svn at 6-8lpm. There was no response or change at all in presentation.
We can patch for Mag 50mg/Kg in 50cc's over 20 minutes.
No standing order for Epi IM- but usual dose is .005-.01mg/kg IM, repeat in 10-20 minutes if no response.

Vitals 
117/71
131 S/R sinus tach on monitor with no ectopy
32 labored resps with wheezes throughout, unable to say more than 1 word at a time.
94% Sa02
Cap refill delayed +3 seconds
Cool and clammy with cold extremities.
End tidal not available on our monitor.

1st problem-Rescue Ambulance coming from 4th due area about 15-17 minutes away.-No way to fix this.
2nd problem-Patient becomes frantic when attempting to establish IV so it is withheld initially. Attempted to fix by calming and reasurring pt and trying to remove family members from the area to calm her down. IV was established as soon as pt was moved to the ambulance and seperated from all of her family.
3rd problem-Unable to contact Base Hospital initially for orders for IM epi. Epi was given and when we finally contacted base Dr agreed with epi decision and said to repeat dose if needed and to hold off on mag.

What are some of the things that you guys would have done for this patient, what our your protocols for Pediatric resp distress/brochospasm?


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## abckidsmom (Dec 20, 2010)

This sounds like a sick little kid.  She's on the edge of respiratory failure, and I would not be surprised to see a kid presenting like this crash and crash hard within minutes.

I'd keep her on a continuous neb, give her epi, and hang the mag.  If the doctor wanted me to hold off on the mag, I'd convince him that was not a good idea.  You used all the right words typing this up, but if the online medical control doctor heard those and still wanted you to hold off on the mag, I'd probably take her to a different hospital.

Edit:  With the all-night respiratory distress, I'd probably give her a bolus of fluid, too.  She's probably dry.


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## Shishkabob (Dec 20, 2010)

Epi, asap, by either IV or IM/SQ, whatever is quickest.  

Try some inline Albuterol/atrovent forced in with CPAP / BVM if you have the ability.



All else fails, they just bought themselves a tube as they are closing in on, if not already at, failure.


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## vquintessence (Dec 20, 2010)

Well it sounds like you treated with the pts best interests and to the best of your abilities.  Her tachypnea, restricted air movement, poor spO2 (presumably on the neb?) and overall work of breathing certainly meet the criteria.

From my uncomfortable armchair, I would like the consideration of solu medrol and fluids.


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## Shishkabob (Dec 20, 2010)

Solu-medrol is much too slow acting for what's currently needing to be fixed.  Potentially nice after we get her breathing again, but Epi first and foremost.


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## vquintessence (Dec 20, 2010)

Linuss said:


> Solu-medrol is much too slow acting for what's currently needing to be fixed.  Potentially nice after we get her breathing again, but Epi first and foremost.



Clearly, but the key is synergy.  He already gave the O2, duoneb, epi and was denied mag.  Steroids certainly are within this childs future.


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## reaper (Dec 20, 2010)

Have you ever used it on a completely shut down asthma pt?

It does act rather quickly in these cases and if is available, should be used sooner, then later.


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## abckidsmom (Dec 20, 2010)

reaper said:


> Have you ever used it on a completely shut down asthma pt?
> 
> It does act rather quickly in these cases and if is available, should be used sooner, then later.



Yep, that's why it's out there.  The sooner it's given, the sooner the effects will start, usually in hours, but sometimes sooner.


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## reaper (Dec 20, 2010)

It can work in as little as 15 minutes in severe bronco spasms. 

For normal treatment it will work within 30-90 minutes. In severe cases, it is very fast acting. I have seen it work in under 10 minutes to take a asthma pt from no air movement to severe wheezing. Which them allowed the duoneb to take affect and do its job.


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## Shishkabob (Dec 20, 2010)

reaper said:


> Have you ever used it on a completely shut down asthma pt?
> 
> It does act rather quickly in these cases and if is available, should be used sooner, then later.




Yes, useful, but Epi is higher on my priority list over a steroid for what needs to be done NOW to prevent the worst outcome.


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## vquintessence (Dec 20, 2010)

mc400,

Just out of curiousity, were you the one to communicate with OLMC?  abckids already alluded to the question, but what was the wording on the patch that ended with OLMC denying the mag infusion?


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## mc400 (Dec 20, 2010)

Thank you, forgot to mention that once IV was established and we were e/r to the er I pushed 62.5 mg of solu-medrol along with 10cc/per kilo bolus and ended up giving a total of 375cc or so. 

We have disposable cpap but only mask sizes for large and small adults, but the small is still too big. Had the inline set-up and BVM was next on the list. Without RSI the tube was going to be a real problem. ER was set up to RSI her upon arrival but she was slowly, really slowly improving and they held off. Pt ws transported out to the childrens hospital about 30 minutes farther away.

We tried to help educate the family as well, hoping next time they will not wait nearly as long to call 911 or seek help in some way. I did not like ths call at all, I had reactive airway disease as a child and vividly remember feeling like she was.


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## abckidsmom (Dec 20, 2010)

mc400 said:


> Thank you, forgot to mention that once IV was established and we were e/r to the er I pushed 62.5 mg of solu-medrol along with 10cc/per kilo bolus and ended up giving a total of 375cc or so.
> 
> *We have disposable cpap but only mask sizes for large and small adults, but the small is still too big*. Had the inline set-up and BVM was next on the list. Without RSI the tube was going to be a real problem. ER was set up to RSI her upon arrival but she was slowly, really slowly improving and they held off. Pt ws transported out to the childrens hospital about 30 minutes farther away.
> 
> We tried to help educate the family as well, hoping next time they will not wait nearly as long to call 911 or seek help in some way. I did not like ths call at all, I had reactive airway disease as a child and vividly remember feeling like she was.




Were you wishing you could have used the CPAP for her?


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## mc400 (Dec 20, 2010)

No the rescue medic patched while I was getting the line. He outlined what we had pretty good making the impression of a very sick kid who was not responding well enough to any of the prvious treatments. I am not sure why exactly the Dr refused Mag, I did not have a chance to ask him but I will try next shift if possible. We had a hard time getting mag protocols at all for adults so they are probably even more apprehensive for peds? I have seen mag work wonders on adults who do not respond to combivent, epi, cpap, etc.


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## mc400 (Dec 20, 2010)

Yes I would have most likely used cpap if it was available. Only problem I see is how anxious this child already was and being able to get the mask on her..


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## abckidsmom (Dec 20, 2010)

mc400 said:


> Yes I would have most likely used cpap if it was available. Only problem I see is how anxious this child already was and being able to get the mask on her..



Did you notice how long her expiratory phase was?  Do you think that she had more problems moving air into her lungs or out of her lungs?

CPAP is not really the best idea for asthma (or whatever severe bronchospasm she's having).  She's already got pretty high airway pressures, and adding to them is not going to be really helpful.

In her case, adding CPAP would have increased her tidal volumes, while at the same time making the expiratory phase be an even higher percentage of the total time of each ventilatory cycle, time that she was spending trying to breathe out against the 5 or 7 of PEEP that the CPAP mask added to the situation.

CPAP is a great tool, but not for a person in respiratory failure of a constrictive nature.

A quick google told me it's not competely unheard of, and won't be fatal, but it's not going to help, if you think about how it works, and what the physiology of her problem is to begin with.


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## mc400 (Dec 20, 2010)

She was breathing rapid with about the same amount of time for both phases. I would have liked to see an end tidal reading but our set up does not support using nebulized meds and the monitor on our truck is not compatable anywyas, which is a whole other can of worms we are fighting with everyday.

I would have probably given it a shot to see if it would help and possibly allow the neb'd meds to get in better. With the way she was breathing I could imagine most of the meds were wasted or spread around her oral cavity and not deep in her lungs. 

We are supposed to use cpap on adults with bronchospam not resonding to high flow o2 and nebulized meds per our protocol but I do understand the issue at hand. Same thing with copd'rs with weak lungs. I transported a patient with a pneumo secondary to aggresive cpap application by a crew.


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## abckidsmom (Dec 20, 2010)

mc400 said:


> She was breathing rapid with about the same amount of time for both phases.



This is key, though.  She's so air-hungry that she's not even able to allow for complete exhalation.  She was stacking breaths, and not exchanging the air.  I'm surprised to hear that the phases were equal.

 I'd have been just a little leary of it without full RSI ability, but it sounds like she needed just a whiff of some benzo, too, just to remove a little of the anxiety component.


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## mc400 (Dec 20, 2010)

I agree with the benzo, I would have liked to give the family some benzo's too lol.


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## abckidsmom (Dec 20, 2010)

mc400 said:


> I agree with the benzo, I would have liked to give the family some benzo's too lol.



Right?  Aerosolized benzos for the whole bunch!

I'm glad you shared this scenario, it's been a while since I have seen a sick kid IRL, it's nice to think this stuff through every once in a while.


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## mc400 (Dec 21, 2010)

I love this site for that very reason. I like to read things like this and I learn a lot by reading other experiences as well as feedback on my own. This was the sickest non trauma kid I have had in a while and it was a rough call.


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## Mobey (Dec 21, 2010)

abckidsmom said:


> Did you notice how long her expiratory phase was?  Do you think that she had more problems moving air into her lungs or out of her lungs?
> 
> CPAP is not really the best idea for asthma (or whatever severe bronchospasm she's having).  She's already got pretty high airway pressures, and adding to them is not going to be really helpful.
> 
> ...




Gotta chime in here.

CPAP is indeed a good choice for the status asthmaticus pt. The physiology is this: In a bronchostrictive event, the bronchiolies are swollen, mucous covered, and in spasm. Since inhalation is an active phase, the inhaled air is forced through the bronchiolies into the alveoli. However
During exhalation (passive), the bronchiolies close off and the air is trapped in the alveoli where it becomes O2 depleted. (Think of a woopie cushion)

So: CPAP increases airway pressures on the exhalation phase (well both actually but just stick with exhalation). By keeping some "backpressure" in the bronchiolies, it effectively splints them open. In this way, it recruits alveoli, reduces air trapping, and actually reduces the chance of a pneumothorax. This increases tidal volumes, reduces terminal airway pressures, improves oxygenation, and improves ventilation (getting rid of C02).


http://chestjournal.chestpubs.org/content/123/4/1018.full
http://chestjournal.chestpubs.org/content/125/3/1081.full
http://www.ncbi.nlm.nih.gov/pubmed/11355116?dopt=Abstract


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## Smash (Dec 21, 2010)

Mobey said:


> Gotta chime in here.
> 
> CPAP is indeed a good choice for the status asthmaticus pt. The physiology is this: In a bronchostrictive event, the bronchiolies are swollen, mucous covered, and in spasm. Since inhalation is an active phase, the inhaled air is forced through the bronchiolies into the alveoli. However
> During exhalation (passive), the bronchiolies close off and the air is trapped in the alveoli where it becomes O2 depleted. (Think of a woopie cushion)
> ...



Whilst there may be potential for non-invasive mechanical ventilation to become part of the treatment of severe, acute asthma, I think we are a long way to go before we can or should say that it is a good choice.

There is an absolute lack of data for the safety and efficacy of NIMV at this stage.  The references you have supplied and that are linked in the Chest journal are interesting, but they do nothing more than suggest a course for further research.

The Fernandez study enrolled only 22 patients, was retrospective and observational and allowed bias in that the ICU Dr decided whether or not to utilize NIMV or intubate.  It was also set in an ICU, so it may not be applicable to emergent or prehospital settings.

Sorosky produced an interesting pilot study that at least was randomized, but again, in an ICU setting and utilizing BiPAP, which is not commonly available in the field, rather than CPAP, which is what most of us are carrying.  It also had a very small sample size (N=33) and did not actually compare with standard treatment or placebo.  Treatment was also stopped to give nebulizers.

The only other article that the Chest review quotes is Meduri's trial with a VERY small sample size (N=17), BiPAP rather than CPAP, ICU rather than ED or field setting and again is retrospective.

There is an absolute dearth of papers on this, and the ones that do exist have appallingly low numbers of patients enrolled.  The larges is Beers 2005 one I think, with about 80 patients, but it was not worth the paper it was written on.

The physiology might sound compelling, but as we discover on nearly a daily basis, what we think sounds good from a physiological standpoint often ends up being really bad for patients in the real world.

The jury is very much still out, or indeed has not even been sworn in yet, when it comes to CPAP in acute asthma, and I would certainly not be treading that path myself without a lot more data to back me up.


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## Shishkabob (Dec 21, 2010)

abckidsmom said:


> CPAP is a great tool, but not for a person in respiratory failure of a constrictive nature.



Meh, CPAP is much like intubation in this case: Not the most ideal solution, but if it works, than great, especially if you can do inline beta-agonist.   Give it a quick trial before you move on to RSI.  

I've done CPAP on an asthma patient before and it was fantastic, sudden turn around that helped the patient.   Granted the agency I was with didn't have RSI so it was all we had to give it a shot.



Just like intubation / RSI... the problem isn't getting air in, it's getting it out, but if they are having trouble getting it in you need to do something to correct that NOW.


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## 18G (Dec 21, 2010)

> CPAP is not really the best idea for asthma (or whatever severe bronchospasm she's having). She's already got pretty high airway pressures, and adding to them is not going to be really helpful.



I gotta admit I am surprised to see the reluctance to use CPAP with obstructive pulmonary disease. Many think that with asthma the CPAP will just compound the air trapping and positive intrathoracic pressures but this is not true. 

An asthma patient with moderate to severe exacerbation will develop increased chest pressure... this is where CPAP comes in and works. If you think of the basis mechanics of breathing and pressure gradients its not hard to understand the role of CPAP in asthma (or COPD). 

These asthma patients need to overcome (ie create an even high pressure) the increased positive pressure before any airflow will occur. This takes massive amounts of energy, accessory muscle usage, and increases overall work of breathing dramatically. CPAP takes the workload off the patient by creating this higher pressure for the patient thus eliminating energy expenditure, rate of oxygen consumption, reduces accessory muscle usage, and reduces work of breathing. And CPAP allows greater (deeper) delivery of nebulized medications. 

CPAP IS RECOMMENDED for asthma and COPD exacerbations and should be used without hesitation with a critical asthma patient. 

Our options are to try CPAP or allow the kid to continue to deteriorate to the point of respiratiry failure and then intubate... the second is not the best choice. Trying to have an asthma patient ventilate through a straw is not good! 

Our protocols are written with CPAP to be used in asthma and COPD. Even before Epi for asthma. 

CPAP is the best choice!


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## MrBrown (Dec 21, 2010)

Medical control strikes again, you have to ring up and ask for adrenaline? ... *Brown shakes his head sadly

Brown would start an adrenaline drip, administer some IV corticosteriods and mix up ketamine in a bag of D5 because she is going to be anaesthetised and intubated.


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## jrm818 (Dec 21, 2010)

Smash said:


> Whilst there may be potential for non-invasive mechanical ventilation to become part of the treatment of severe, acute asthma, I think we are a long way to go before we can or should say that it is a good choice.
> 
> There is an absolute lack of data for the safety and efficacy of NIMV at this stage.  The references you have supplied and that are linked in the Chest journal are interesting, but they do nothing more than suggest a course for further research.
> 
> ...




I can't disagree with the analysis of any of the data, but anecdotally I've heard some pretty strong support for the use of BiPAP/CPAP for use in asthma.  Personally I would have thought that CPAP was worth a try in this case, and I'll admit some confusion on the issue.  

Anecdote is pretty weak however, and unfortunately it may be pretty difficult to conduct a large prospective, randomized, ED/EMS based trial of this issue.  It has been tried, but the trial failed due to non-compliance:

http://www.ncbi.nlm.nih.gov/pubmed/11733289

This was an attempt to conduct such a study, with an n goal of about 670.  After 35 patients the trial halted, due to reluctance (on the part of both patient and physicians) to allow asthmatics to be enrolled in a study which might possibly deny them BiPAP.

The paper was written up more as an analysis of a attempt to use statistical methods (that I don't pretend to understand ) to eke out some useful information by using calculations that include the pre-study probability of treatment success according to the providers in the study.  

The value (or lack thereof) of this data in demonstrating a befit for BiPAP aside, they found that, according to their fancy Bayesian calculations, in order for the small amount of data actually collected to demonstrate a benefit to BiPAP treatment that was "convincing at the 95% confidence level," physicians would have to have had a 98.9% "prior conviction of BiPAP as a successful treatment modality."  Yet there was a revolt against allowing patients to be enrolled in the control group, suggesting that the prior conviction may have been pretty close to that number.

In other words, these physicians were probably very sure that BiPAP would be successful prior to their patients being enrolled in the study.  Given this, think it's understandable that in the EMS world there would be some confusion over whether PAP may be beneficial in severe asthma, since there are obviously some groups of physicians (One of whom I bet was a EMS medical director) that are obviously very sold on the treatment, some physicians that may disagree, some faceless (but very smart) posters on a website saying no go, and no real clinical data other than small (but leaning positive) reports. 



I think the question raised is this: is it true that large peer reviewed studies are the only type of valid clinical data to be used when making a treatment decision?  

Granted expert opinion and anecdote are the weakest form of evidence, but what do we do when there is no good data from large prospective trials (especially if there may never be such data, as in rare conditions or cases like this where there is provider resistance to even conducting a trial)?  Is "weakest form of evidence" the same as "no evidence?"

Might it be reasonable to try an "unproven" therapy in an emergent situation when there is a lack of data, rather thane evidence of harm?  Does this change with the likelihood that the clinical question will ever be answered?

I honestly don't know for sure, although I'd be inclined to lean towards the "give it a trial" side, given that it's impossible to provide good evidence for every possible treatment decision, clinical presentation, or individual patient.


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## WTEngel (Dec 21, 2010)

Status asthmaticus patients do respond well to use of CPAP to re recruit alveoli. It was common practice on the peds critical care team I used to work for. If you can get past the short time of them fighting it, they begin to oxygenate better, more alveoli means better gas exchange, and as they get less hypoxic you will see them become more reasonable.

One of the worst things we can do long term for asthma patients (especially peds) and COPDers is intubation. Intubation turns increases the admit time of these patients considerably.

We used to get so frustrated with adult ERs intubating peds asthma patients without a second thought. I don't like to Monday morning QB another provider's clinical care, but intubation should be the last last option.

Also, steroid treatment shouldn't be overlooked if practical. It won't make much difference in the field, but the results can be seen within a few hours, so the sooner the better.

I tend to agree with most everyone here, mag would have been a good choice, but it seems in this case everything worked out well. Kudos for considering in line nebs. A lot of providers overlook in line nebs, because they lose sight of the primary problem (bronchspasm and constriction) after they've taken over the patient's airway.


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## mc400 (Dec 21, 2010)

MrBrown said:


> Medical control strikes again, you have to ring up and ask for adrenaline? ... *Brown shakes his head sadly
> 
> Brown would start an adrenaline drip, administer some IV corticosteriods and mix up ketamine in a bag of D5 because she is going to be anaesthetised and intubated.



Yes for some reason our peds protocol does not allow offline administration of epi. I am in the process of getting info together and approaching our docs with a change to the protocol. Our adult protocol has epi as an offline option as well as mag. Basically Albuterol/Atrovent, Cpap/BVM both with inline neb'd meds, Epi, Mag. Our Peds read alb/atr, patch for mag. No mention of epi at all unfourtunately, we had to make a judgement call and the dr. agreed with us anyhow. Hopefully we can get the chasnge made.

In our croup/stridor protocol we can give neb'd epi 3mg/5cc saline under 4, and 5mg/3cc saline over 4 years old. 

We also do not have ketamine at all. Sadly our choice is to wait until unc. to intubate or try and sedate enough with versed to facilitate intubation.


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## Veneficus (Dec 21, 2010)

abckidsmom said:


> You used all the right words typing this up, but if the online medical control doctor heard those and still wanted you to hold off on the mag, I'd probably take her to a different hospital.



I would give her the mag, epi, and steroids undoubtably.

But it is not a standard practice and the effects are somewhat variable. It is not worth diverting to a different hospital or doctor shopping.

There are 2 mechanisms by which mag acts. One is to reduce the function of T cells, the other as a smooth muscle relaxor.

If the airway has already reached a critical level of imflammatory response, the mag is unlikely to help acutely. 

I would attempt an IM Epi, and if it worked, perhaps follow it up with a nebulized one. 

A couple things to consider is if this patient has ever been intubated for asthma prior, and if the duoneb is not helping, there exists the possibility of an infection rather than a hyperimmune response.


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## 18G (Dec 21, 2010)

Our protocols regarding epi are kinda strange... for anaphylaxis we don't need to call but for asthma/COPD we do. Guess maybe they don't want providers gunning for the epi until they have tried nebs and CPAP. But if the patient is already in extremis with no air exchange for the nebs to get where they need to be you may need to go straight to epi. Not sure what the rationale is for this.


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## Veneficus (Dec 21, 2010)

18G said:


> Our protocols regarding epi are kinda strange... for anaphylaxis we don't need to call but for asthma/COPD we do. Guess maybe they don't want providers gunning for the epi until they have tried nebs and CPAP. But if the patient is already in extremis with no air exchange for the nebs to get where they need to be you may need to go straight to epi. Not sure what the rationale is for this.



probably caution. 

The epi will expand the bronchi, but will also constrict the vessles and increase myocardial demand.

At one point epi was the standard of treatment, but that was a long time ago.


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## Aidey (Dec 21, 2010)

Just to point out a potential issue, how many people carry a pediatric CPAP mask? We have a 1 size first most set up, and I highly doubt it would seal on an 8yo.


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## mc400 (Dec 21, 2010)

We have a large adult and small adult mask. 

also good question this child had never been intubated before.


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## Fox800 (Dec 21, 2010)

Epi first line medication, IM for us, and swap the child over to our meds/neb at 8LPM. Establish IV, start mag infusion. When practical, administer methylprednisolone and small fluid bolus. Have a BVM and advanced airway equipment nearby. If the kiddo starts to decomp, BVM with neb attached...followed by intubation if needed.


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## mc400 (Dec 22, 2010)

I like those standing orders. Life would be much easier. In due time I guess.


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## Smash (Dec 22, 2010)

jrm818 said:


> I think the question raised is this: is it true that large peer reviewed studies are the only type of valid clinical data to be used when making a treatment decision?
> 
> Might it be reasonable to try an "unproven" therapy in an emergent situation when there is a lack of data, rather than evidence of harm?  Does this change with the likelihood that the clinical question will ever be answered?
> 
> I honestly don't know for sure, although I'd be inclined to lean towards the "give it a trial" side, given that it's impossible to provide good evidence for every possible treatment decision, clinical presentation, or individual patient.



I know what you are saying: Lack of evidence is not evidence of lacking.  I agree with you on that, and I also agree that we need not necessarily be a slave to statistics, but to use our clinical judgement to identify and treat problems as we find them, pertaining to a specific patient in a specific setting.

The trouble I have with this in this particular setting is that there is potential for harm to come from trying the unproven treatment in the field.  With all due respect to all the posters here, I would be a lot more comfortable deferring to a physicians gestalt than a paramedics (mine included) in trying out new things on sick patients (and that's not something most of them do).  

Personally I have not seen that many sick asthmatics in the last year or so, only had to intubate 4 in the last 3 months, 3 respiratory arrested and one cardiac arrested, and had a dozen or so in the same time frame who were "sick".  It may just be my lack of confidence, but that doesn't make me feel comfortable stepping outside the normal standard of care to try something new and unproven.
There is also a large difference between a physician using BiPAP or PAV in an ED/ICU setting as compared to a paramedic with a WhisperFlow or Boussignac device slapping it on in the back of an abulance.

I may be wrong about CPAP for acute asthma, but if so I am wrong within the bounds of currently accepted knowledge, standards and clinical practice.  I would much rather this than be wrong when stepping outside those parameters.

I think that the clinical question will be answered eventually, notwithstanding the issues in gathering data.  We may not ever get the big NEXUS sized killer study to answer it, but with a larger number of smaller but methodologically sound RCTs we may be able to paint a clearer picture in the future.



18G said:


> CPAP IS RECOMMENDED for asthma and COPD exacerbations and should be used without hesitation with a critical asthma patient.


Recommended by whom?  Certainly not the British Thoracic Society nor the American Thoracic Society outside of clinical trials.

Given the lack of evidence and the potential for harm it is somewhat reckless to suggest that an unproven treatment should be used "without hesitation".  Unless you can back this up with some science?



> CPAP is the best choice!



It may be the choice of your medical director, but "best" is a very relative term.


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## Akulahawk (Dec 22, 2010)

If you're carrying CPAP or a BiPAP machine on your unit, why not push to also carry a heliox or a tri-mix breathing gas for use in bronchospasm/status asthmaticus patients? (cost of the gas notwithstanding)


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## 18G (Dec 22, 2010)

Smash... our protocols are state-wide medical protocols which are pretty aggressive and science based. They are not created off of a single person's belief. Based on currently available data CPAP is being shown to be effective in the obstructive pulmonary group of patients. The physiology of why CPAP would be beneficial makes sense to me. 

I am all for research based EMS... I want validity for what we do. But at the same time people are going way overboard with touting what can be done or should be done based on this study or that study. 



> The trouble I have with this in this particular setting is that there is potential for harm to come from trying the unproven treatment in the field. With all due respect to all the posters here, I would be a lot more comfortable deferring to a physicians gestalt than a paramedics (mine included) in trying out new things on sick patients (and that's not something most of them do).



Who said were experimenting? CPAP for asthma has been studied if even only small scale, the data supports it, and anecdotally it works very well in a lot of cases. The suggestion of letting people progress to respiratory failure before deciding to act solely because we have no multiple, large, double-blind trials is crazy. 

I would much rather try CPAP than wait to intubate an asthma patient any day. There is enough resistance to airflow already so now lets place a straw in their throat for em to breathe through with overzealous providers who don't control the ventilation rate or allow extra time for exhalation... now we have extreme breath stacking and lots of increased pressure in the chest... yeah that makes sense.



> It may be the choice of your medical director, but "best" is a very relative term.



Yeah, relative to intubation it is the best modality to try first.


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## 18G (Dec 22, 2010)

... and call it experimenting or whatever you want, but its what we do in the field that creates much of the data for these later, large scale studies to validate the effectiveness of what we do.


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## Veneficus (Dec 22, 2010)

I would just like to point out.

The limit of "evidence" based medicine is that it is based around what works best for the most number of patients in a select group. 

It is also based on very strict parameters of diagnosis and enrollment. 

In medicine, but especially in field medicine, it is often difficult if not impossible to reach definitive conclusions on diagnosis. (Not that we shouldn't try.) 

We must be very careful on absolute statements like "always" or "never."

Studies that establish practice guidelines in medicine are invaluable, however, it is also important to recongnize and understand the limitations of them.

One of the things I have noticed, as medicine becomes more fragmented in the effort of hyperspecialization, is that various specialties have stopped communicating or seeking the others advice.

Despite the "decreased complications" and "better outcomes", for various disease states, patients often have more than one disease and the treatments of these noncommunicating specialists often interfere with each other and cause undue patient confusion. Which I strongly suspect increases complications and creates worse outcome. (polypharm is a very good example.)


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## Shishkabob (Dec 22, 2010)

Fox800 said:


> Epi first line medication, IM for us, and swap the child over to our meds/neb at 8LPM. Establish IV, start mag infusion. When practical, administer methylprednisolone and small fluid bolus. Have a BVM and advanced airway equipment nearby. If the kiddo starts to decomp, BVM with neb attached...followed by intubation if needed.



Pretty much same as us, except we have IM/SQ OR IV Epi, depending on what we can get the quickest.  



Aidey said:


> Just to point out a potential issue, how many people carry a pediatric CPAP mask? We have a 1 size first most set up, and I highly doubt it would seal on an 8yo.



We have large adult, small adult and pediatric.


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## 8jimi8 (Dec 22, 2010)

continued reading and realized my post was completely unneeded.


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## MrBrown (Dec 22, 2010)

8jimi8 said:


> continued reading and realized my post was completely unneeded.



Just like most of Browns


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## HappyParamedicRN (Dec 22, 2010)

This makes me appreciate NH, where everything except The Heparin we carry for STEMIs is standing order!

Happy


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## Smash (Dec 23, 2010)

18G said:


> Smash... our protocols are state-wide medical protocols which are pretty aggressive and science based. They are not created off of a single person's belief. Based on currently available data CPAP is being shown to be effective in the obstructive pulmonary group of patients. The physiology of why CPAP would be beneficial makes sense to me.



What science?  Mobey posted some studies, including pretty much the only methodologically sound but nonetheless underpowered and not necessarily applicable to the field study.  If your protocols are science based, you should be able to reference the science behind them, otherwise they are opinion.  

The currently available data is not showing that CPAP is effective in acute asthma, it is not powered to.  It has certainly shown that it is a promising treatment modality that should be investigated further, but it is a far cry from definitive or even universally accepted.

The physiology of CPAP does seem to make sense.  But then the physiology of furosemide for cardiogenic pulmonary edema made sense, the physiology of bicarb in arrest made sense, MAST pants made sense, bretylium made sense, plavix makes sense, tPA for stroke makes sense... none of which means much at all.



> I am all for research based EMS... I want validity for what we do. But at the same time people are going way overboard with touting what can be done or should be done based on this study or that study.



If we are not basing our practice off research, then what?  Do we really want to continue with eminence based practice?





> Who said were experimenting? CPAP for asthma has been studied if even only small scale, the data supports it, and anecdotally it works very well in a lot of cases. The suggestion of letting people progress to respiratory failure before deciding to act solely because we have no multiple, large, double-blind trials is crazy.



When the evidence does not exist to support it's use then it most certainly is experimenting, whether it is overtly in the form of a trial or not.  That's fine if you are happy collecting data; in fact we need more of that, but to suggest that the data supports it's use as it stands is simply not true.




HappyParamedicRN said:


> This makes me appreciate NH, where everything except The Heparin we carry for STEMIs is standing order!
> 
> Happy



Cool, can we discuss the evidence for heparin in STEMI now?


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## para1medic (Dec 28, 2010)

mc400 said:


> 8 year old Female. Pt in tripod position with obvious distress and working hard to breathe. 32 resp/min lungs sound coarse and very tight. Pt appears very tired... cap refill >3 seconds



That right there is all the assessment I need -- IMMEDIATE epi 1:1000 IM, then worry about starting a line. You've obviously got severe pediatric asthma with multi-system involvement: respiratory, neuro, and circulatory. Immediate Epi. Do not stop, do not pass go, do not waste time setting up your neb.  Immediate Epi, then worry about starting a neb treatment and an IV and putting her on the monitor and getting orders for steroids and all that jazz.

EPI FIRST for pediatric respiratory with multi-system involvement.


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## mc400 (Dec 29, 2010)

I agree 100%. Hope to get our peds standing orders changed soon. Like stated Its alb/atro svn, patch for mag infusion. No epi even on the protocol......Why I do not know, it is what every doc says to do and wants.


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