Benzos in asthma

[glorfindel]

---

Members don't see this ad.

My practice since residency has evolved. (!!)

When an asthmatic hits the door, I give them:

1) albuterol
2) steroids
3) +/- epi
4) +/- magnesium
5) benzo

I suspect if you did a study about benzos in asthma (and copd), it would demonstrate that benzos reduce the time to discharge for those discharged from the ED, and might even reduce the number of patients requiring ETT.

I remember in residency: a woman with severe, real asthma, who was a frequent flyer, and who'd been intubated many times before, but who often would resolve in the ER and be discharged when given a benzo as soon as she hit the door. If the resident on that day didn't know her, and forgot the benzo, she stayed longer and would often get tubed.

 

[deleted6669]

along similar lines how do you all feel about low dose ketamine ( 0.1 mg/kg) for patients with significant asthma? I have seen folks talk about this but have never seen it done.

 

[Birdstrike]

I don't know about the science behind it, but you both will excel at patient sat

 

[la gringa]

along similar lines how do you all feel about low dose ketamine ( 0.1 mg/kg) for patients with significant asthma? I have seen folks talk about this but have never seen it done.

i have done it once, pt's bronchospasm got much better but he still looked like he was about to crump so i tubed him.

probably should have done a benzo too though 😉

 

[RustedFox]

along similar lines how do you all feel about low dose ketamine ( 0.1 mg/kg) for patients with significant asthma? I have seen folks talk about this but have never seen it done.

Done it once for young female asthmatic. She was 5'5'' x 5'5'' x 5'5''. It worked; we didn't need to tube her and we got her thru the worst of her asthma attack.

 

[glorfindel]

I don't know about the science behind it, but you both will excel at patient sat

Yeah, my patients' sats are always > 95%

Their satisfaction? So-so.

 

[Birdstrike]

Yeah, my patients' sats are always > 95%

Their satisfaction? So-so.

With all the benzos, you'll get 100% (PG score) every time

JK


Press-Ganey Mantra: Suck It Up

http://www.epmonthly.com/whitecoat/2013/01/press-ganey-mantra-suck-it-up/

 

[la gringa]

With all the benzos, you'll get 100% (PG score) every time

JK


Press-Ganey Mantra: Suck It Up

http://www.epmonthly.com/whitecoat/2013/01/press-ganey-mantra-suck-it-up/

if they're that sick though, they're getting admitted... and i have yet to work anywhere that measures PG for the EP for admitted pts. 👎

 

[Birdstrike]

if they're that sick though, they're getting admitted... and i have yet to work anywhere that measures PG for the EP for admitted pts. 👎

I know

Joking

 

[la gringa]

joking, but there's a real issue at hand there. very frustrating!!

 

[squad41]

glorfindel-

what kind of benzos we talking? 1mg Ativan IV x 1 or what? After they've gotten nebs?

Interesting topic...

 

[Arcan57]

My practice since residency has evolved. (!!)

When an asthmatic hits the door, I give them:

1) albuterol
2) steroids
3) +/- epi
4) +/- magnesium
5) benzo

I suspect if you did a study about benzos in asthma (and copd), it would demonstrate that benzos reduce the time to discharge for those discharged from the ED, and might even reduce the number of patients requiring ETT.

I remember in residency: a woman with severe, real asthma, who was a frequent flyer, and who'd been intubated many times before, but who often would resolve in the ER and be discharged when given a benzo as soon as she hit the door. If the resident on that day didn't know her, and forgot the benzo, she stayed longer and would often get tubed.

Do you whip out the benzos in kids or patients that have minor wheezing and are essentially there for an albuterol refill? Also, I wonder if you were treating asthma or vocal cord dysfunction? We had a woman in residency that ended up getting trached due to severe wheezing with retractions and eventually developing stenosis due to be intubated so many times. The kicker is her reactive airway disease was actually mild, she just had an untreated anxiety disorder and vocal cord dysfunction.

 

[Birdstrike]

joking, but there's a real issue at hand there. very frustrating!!

What, that patient sat scores don't count the sickest people, those who are admitted, who are the very people ER doctors are put on this Earth to treat?

If so, that's why I linked Whitecoat's post today (above), which further indicts the entire medical-patient-satisfaction industry, in a very different way: in their own words.

You need to read Whitecoat every day (and not because he lets me post there on occasion). I can't hold a candle to that guy. He's taking the lead to expose so much fraud and injustice it's amazing. Emergency Medicine owes that guy.

 

[ORL10]

I give low dose benzos if the alternative is intubation, because if they get sedated then I intubate them, same mantra for the old guy with CHF who is ripping off the bipap mask. I use ketamine in asthmatics when S*** hits the fan, and haven't been that impressed in terms of its ability to save intubation. I do use ketamine as my induction agent and sedation agent for intubated patients with reactive airway disease (and sepsis to be honest), but it usually has to be coupled with something else as I have found its sedative properties for continuous sedation to be less than ideal for the first 6 hours. BiPAP has saved me a few intubations.

Don't know the pathophysiology of benzo's for reducing bronchoconstriction or airway edema, probably just reduces the OH S*** factor for the patient as they feel like they are suffocating.

 

[glorfindel]

Squad41, I give ativan 1mg IV after the neb, and won't hesitate to repeat it as necessary. [EDIT- after the neb is started, asap]

Arcan57, I usually don't give benzos unless I'm also reaching for the mag and thinking about the epi, which excludes a lot of mild wheezers, refill-seekers, etc. I'll give benzos to kids. The reason I give the benzo is because I find it hard to differentiate sometimes between severe bronchospasm, and milder bronchospasm exacerbated by severe anxiety -- they can sometimes look really similar. I'm sure I wouldn't have been able to differentiate a severe asthmatic from a severe anxiety disorder with vocal cord dysfunction. The best part is, the benzo isn't going to hurt anyone, and it'll help in a not-insignificant number of cases.

ORL 10, I don't know the pathophys either, but I'm pretty sure the benzos aren't doing anything to reduce bronchoconstriction or edema. In my practice, benzos have saved me from a few intubations. I suspect it's because in some cases, severe anxiety --> hyperpnea --> air trapping --> co2 retention and fatigue --> respiratory failure. And if that sequence doesn't hold up, it's certainly true in some cases that giving a benzo makes the patient look a whole lot better --> me choosing not to intubate them. In the alternative scenario, patient continues to look really ****ty --> I pull the trigger on the ETT.

Birdstrike, I'm adding White Coat to my reading list. Anyone who's exposing fraud and injustice gets a +1.

 

[glorfindel]

Low-dose ketamine for asthma? I've never tried it. I'm looking forward to trying it, though...

 

[bad virus]

No one gets to steal this because I'm doing it.

2.5 year double blind study of glucagon + standard asthma therapy, vs. Placebo + standard asthma therapy on discharge time.

I've seen a few studies, but they all had somewhere around 60 patients total. Haven't worked any kinks out yet, but I call dibs on it.

 

[name?]

Low-dose ketamine is quite nice (0.5mg/kg-1mg/kg) in the flailing asthmatic. I use benzos sparingly as I hate to make the tired asthmatic more sleepy, but in the awake, tachypneic, but satting well patient who is non-diaphoretic and just anxious as hell, ativan 1mg IVP can be wonderful. With the ketamine it's more of a pre-intubatino 'what the hell' maneuver because if they calm down enough to get treatments I may spare the ETT.

 

[docB]

I give low dose benzos if the alternative is intubation, because if they get sedated then I intubate them, same mantra for the old guy with CHF who is ripping off the bipap mask. I use ketamine in asthmatics when S*** hits the fan, and haven't been that impressed in terms of its ability to save intubation. I do use ketamine as my induction agent and sedation agent for intubated patients with reactive airway disease (and sepsis to be honest), but it usually has to be coupled with something else as I have found its sedative properties for continuous sedation to be less than ideal for the first 6 hours. BiPAP has saved me a few intubations.

Don't know the pathophysiology of benzo's for reducing bronchoconstriction or airway edema, probably just reduces the OH S*** factor for the patient as they feel like they are suffocating.

I do this too. I have found it to be helpful in avoiding intubations. I find it most useful in LOL COPDers who have big anxiety components to their pathology.

Low-dose ketamine for asthma? I've never tried it. I'm looking forward to trying it, though...

I'd love to try to too but in my hospitals I can't. It would be considered "procedural sedation" an invoke all the required paperwork and personnel in attendance. Someday maybe.

No one gets to steal this because I'm doing it.

2.5 year double blind study of glucagon + standard asthma therapy, vs. Placebo + standard asthma therapy on discharge time.

I've seen a few studies, but they all had somewhere around 60 patients total. Haven't worked any kinks out yet, but I call dibs on it.

I'd add tube vs. not for an endpoint. That will likely correlate with time to d/c but it would be good data.

As an aside a marker I've found helpful for if someone is going to buy a tube or not is if they can talk. If they can string together 6 or 7 words they usually turn around. If they can't say their name I go straight to BiPAP. I've seen guys who are tripoding, audible wheezes, sats of 89% on 15L but then they start telling war stories and before you know it they're yelling at the nurse about needing to go outside and smoke.