CPAP in ASTHMA? Absolute contraindication?

Christopher; said:
Ativan has helped in some of these situations, but this is where Ketamine would really shine!
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Sure, it may help them tolerate the mask, which is what Scot Whiengart advocates to help you oxygenate while you get set up for intubation. But I don't think it's usually a long term solution. If you have someone who is that sick from asthma, if you sedate them so they tolerate the BiPap, and ten minutes later they've already gotten Solumedrol, mag, epi, continuous nebs and they are not improving I think you are very close to needing to tube.

Note I'm not saying intubation is manditory, but if their person isn't awake they aren't safe to leave on Bipap. So the question is how long are you going to sit there and watch them. I think in the next 10-20 minutes they are either going to tire, start getting hypoxic and get tubed, or they are going to improve and you've dodged a bullet. But I just want to be clear that I don't think the answer is "sedation and BiPap and you are done with them."
 
I use CPAP with inline Neb, Some sort of Steriod and even go the point of using SQ epi, or A Mag Sulfate drip often on bad Patients, I have only seen Patients improve from this treatment.
 
zmedic said:
Sure, it may help them tolerate the mask, which is what Scot Whiengart advocates to help you oxygenate while you get set up for intubation. But I don't think it's usually a long term solution. If you have someone who is that sick from asthma, if you sedate them so they tolerate the BiPap, and ten minutes later they've already gotten Solumedrol, mag, epi, continuous nebs and they are not improving I think you are very close to needing to tube.

Note I'm not saying intubation is manditory, but if their person isn't awake they aren't safe to leave on Bipap. So the question is how long are you going to sit there and watch them. I think in the next 10-20 minutes they are either going to tire, start getting hypoxic and get tubed, or they are going to improve and you've dodged a bullet. But I just want to be clear that I don't think the answer is "sedation and BiPap and you are done with them."
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I'd tailored my comments to their care prior to the ED. Prehospital if I can optimize their ventilation/respiration without RSI, I'm going to take that approach (perhaps I'm in the minority). In the ED, or if unlucky enough and we're still in the field, if they've not improved then we're on the same page: RSI.
 
It looks like the original poster answered their own question. Reasons stated were:

- Lack of evidence in prehospital setting
- May cause increased air-trapping [It makes sense - the wheezing sound heard on expiration is due to the bronchioles constriction and the increased respiratory effort to exhale the processed gas. So adding positive pressure infront of it is only creating more resistance to exhalation.]
- Increased intrathorasic pressure. [This is more of a venous-return/hypotension problem.]
- Irritatoin of bronchioles exacerbating the problem [I think this is a bit of a stretch.]

Another way to think of why this is consideration of the benefits to CPAP...
- Positive alveolar pressure to redistribute (push out) pulmonary edema and effusion [Not a problem with asthma]
- Alveolar recruitment [Not a problem with asthma]
- Ventilation/Perfusion ratio restoration [Not a problem with asthma]

The core of the problem is the bronchiole constriction, so the correct Tx is medication therapy. I think that's where they're going with the 'absolute contraindication' because you would be moving in the 'wrong' direction in your patient care plan.

Now, there's a fair argument to be made about delivery of inhaled medications in persons with reduced tidal volumes... so who knows.
 
Complete anecdote here as far as I know, but we actually carry both Flowsafe in-line neb-capable CPAP and PEEP valves for BVMs for asthmatics. Works like champs.
 
Im pretty agressive when it comes to asthmatics, i usually hit them with epi early, even the moderatly severe payients. But am usually hesitant with the CPAP. Ive seen it make the patient better in the short term (oxygenation) but do little about the airtrapping that is occurring.

But every patient is different and some do improve with inline neb and PPV.

If i do have to RSI its include alot of epi and ketamine.
 
Our protocols allow cpap for asthma patients, but paramedics usually dont really go for it. The other day we had a sick asthma patient and we couldn't get a line started to give magnesium. So i was like lets cpap this guy. The paramedic tutoring me was like nah i dont do that. The em doc agreed its not really accepted in asthma patients but then again, you got a quite sick asthma patient, tube still preventable, i thought its worth trying. The literature i looked at wasnt conclusive but most did say it might help. (Eg tintinali's em)
 
Eden - I'm curious, do you carry EZ-IO? If so, what are your protocols for its use?
 
CWATT said:
Eden - I'm curious, do you carry EZ-IO? If so, what are your protocols for its use?
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We got BIG/NIO ( i'd rather have ez io) and protocols wise its an alternative for iv line. We thought about it but we were close to the hospital so it ended with a neb and epi IM.
 
Eden said:
We got BIG/NIO ( i'd rather have ez io) and protocols wise its an alternative for iv line. We thought about it but we were close to the hospital so it ended with a neb and epi IM.
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We can also sedate and tube with ketamine IM 5mg/kg
 
Eden said:
Nope, I mean 5mg/kg Intramuscular. Definitely not something we do routinely but could do.
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Where do you put it all? The only ketamine I've seen is 10mg/ml, which would be 50ml for a 100kg pt...
 
Underoath87 said:
I'm assuming you mean 0.5 mg/kg (IBW)?
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Most any IM dose of ketamine is going to be 2x the IV dose. A "normal" induction dose is 2 mg/kg IV.

We routinely give 5 mg/kg IM for combative patients.


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Eden said:
Nope, I mean 5mg/kg Intramuscular. Definitely not something we do routinely but could do.
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Well, like most drugs, it actually should be dosed based on LBW. If you use TBW you end up giving quite a bit more than you need to, in the average American.

But 5mg/kg is on the low end of an induction dose so it probably doesn't matter in most people. You may well be underdosing some of your young, lean males at that dose though.
 
Remi said:
But 5mg/kg is on the low end of an induction dose so it probably doesn't matter in most people. You may well be underdosing some of your young, lean males at that dose though.
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Yeah, IM induction dose goes up to 8 or more I think.

As to CPAP vein of the thread, the PEEP element can actually decrease work of breathing and allow the patient to exhale more completely by pressure "stenting" or "splinting" of constricted airways. As long as the CPAP setting is less than the intra-alveolar pressure, it should be beneficial, and 6 - 8 will be less than that in a symptomatic asthma patient.

The issue of requiring some anxiolysis to accept the mask is a real one, but anything other than ketamine (Ativan was mentioned) wouldn't be a great idea, IMO, because of the central depressive effects of benzodiazepines, narcotics, whatever.
 
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