> -----Original Message-----
>
> In a case of severe asthma presentation when patient is not
> YET a definite
> intubation, but close and is moving VERY little air if any and the
> continuous nubeulisers applied are just blowing on his face
> (assume steroids
> have been dealt with), do you
> 1. Nebulise continuously until patient either begins to
> improve or gets too
> exhausted or intubated for another reason?
> 2. Give IV Aminophylline (assume not had it before)?
> 3. Use IV Salbutamol to get some into the system despite him
> not moving any
> resps?
> 4. Use IV/S-cut Epi for same reason as 3.?
> Or any other method?
>
> Especially interested in anyone how has seen something RECENT in
> favour/against option 3 of IV salbutamol.
1; not 2 or 3; add magnesium; have your most able intubator standing by.
Not sure why aminophylline is still used so much- nobody, anywhere, has
shown it to be of benefit, and it has a high incidence of major side effects
(VT, cardiac arrest etc). Great drug in the later stages, though (the
dyspnoeic at rest patient on the ward). Don't trust anecdote on this one-
I've seen too many patients inexplicably and rapidly improve regardless of
treatment.
Beware tachycardia (high intrathoracic pressure, high pulmonary pressure
prolonged filling time).
If it's any help, 3 relevant Cochrane reviews this year:
1. Aminophylline has been extensively studied- no benefit over salbutamol
alone
2. Magnesium is of benefit (although studied in less severe cases)
3. No benefit of IV over inhaled salbutamol (although most recent original
research was 1991, and that compared to inhaled + methylxanthines- I seem to
recall a paper about 3 years ago that looked just at children and showed no
benefit, though).
(Heliox is another possibility of no proven benefit; and I'd want as much
oxygen as possible in the lungs for when the patient arrests)
Not sure about the rationale for inhaled salbutamol- if the patient is
shifting no air at all, that's a full respiratory arrest, so needs
intubation, no argument. If shifting air, prolinged expiratory phase, so
high peak inspiratory flow rate- should shift the stuff. I know about the
selective bronchoconstriction argument (so IV bronchodilates the perfused
areas rather than the areas that are already well ventilated), but has this
ever been shown? Also, the bottom line is 15 RCTs with nearly 600 patients
have failed to show any benefit. What's the rationale behind epinephrine in
asthma?
Matt Dunn
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