Bronchospasm

[Coastie]

Acute bronchospasm in code situations:

Patient fails albuterol/ipratropium, epinephrine 0.01 mg/kg subq. No aminophylline around. Sats are going down.

You're alone in house, attending 15 minutes away.

Management?

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[proman]

Intubated or not intubated? 0.01mg/kg is a small dose for SQ admin (I'd use 0.03)

I'd give IV epi either way and (if possible) a lot of volatile anesthetic. Once oxygenation stabilizes I'd give IV magnesium and steroids.

 

[Coastie]

Intubated or not intubated? 0.01mg/kg is a small dose for SQ admin (I'd use 0.03)

I'd give IV epi either way and (if possible) a lot of volatile anesthetic. Once oxygenation stabilizes I'd give IV magnesium and steroids.

Intubated.

You're on the floor, no volatiles.

IV epi: how much? 1 ug / kg?
IV mag: how much?
Steroids: how much?

0.03 mg / kg subq could = 3 mg of epi subq in a 100kg guy. You sure? I'm also finding lidocaine 1-1.5 mg/kg iv, as well as 0.3mg subq epi.

 

[proman]

The 0.01mg/kg is for pediatric dosing. I think most would give 0.3mg to start SQ in adults. Many would give 0.5mg to 1mg IM or SQ in adults. I wouldn't wait too long if the patient is refractory to treatment and getting hypoxic before moving to IV epi. The recommended dose is 100mcg IV but I'd probably start with less (like 20-40 mcg). I would give 2gm over 10 min. As for steroid, I'd give whatever I could get soonest, and a loading dose. Dexamethasone, hydrocortisone and methylprednisolone are ok.

But, it sounds like this patient needs to be intubated too.

 

[mhause]

Are we talking abot resp. failure due to asthma, or an acute bronchospasm?

 

[Licoricestick]

Intubated.

You're on the floor, no volatiles.

IV epi: how much? 1 ug / kg?
IV mag: how much?
Steroids: how much?

0.03 mg / kg subq could = 3 mg of epi subq in a 100kg guy. You sure? I'm also finding lidocaine 1-1.5 mg/kg iv, as well as 0.3mg subq epi.

IV adrenaline and get to an anaesthetic machine and volatile ASAP.
Meanwhile try ketamine.

 

[Planktonmd]

Suction ETT and make sure you are not dealing with mechanical obstruction and make sure that your ETT is not too deep.
Give muscle relaxant to eliminate any patient resistance to vent.
Adjust vent settings to small tidal volume and long expiratory phase (I/E 1/4 or 1/5).
Give Epinephrine IV at small increments (20-30 mcg) boluses every few minutes.
Give Magnesium sulfate 1g IV.
Try Atropine 0.4 mg IV.
Steroids are probably not very helpful to resolve an acute crisis but it wouldn't hurt to give 10 mg of Dexamethasone.
A pneumothorax should always be considered in these patients.

 

[proman]

Suction ETT and make sure you are not dealing with mechanical obstruction and make sure that your ETT is not too deep.
Give muscle relaxant to eliminate any patient resistance to vent.
Adjust vent settings to small tidal volume and long expiratory phase (I/E 1/4 or 1/5).
Give Epinephrine IV at small increments (20-30 mcg) boluses every few minutes.
Give Magnesium sulfate 1g IV.
Try Atropine 0.4 mg IV.
Steroids are probably not very helpful to resolve an acute crisis but it wouldn't hurt to give 10 mg of Dexamethasone.
A pneumothorax should always be considered in these patients.

Agree with above but the patient is on the floor, not intubated. Anticholinergics haven't been shown to be helpful in adults (only children), but little harm trying. The dose for magnesium should be higher though (RCT indicates 2gm is effective). There's a myth that steriods don't act sooner than 6 hours, but that was before we recognized membrane-associated steroid receptors (that act independent of transcription). Either way steroids don't act fast but should be give at the soonest opportunity.

Once the patient is intubated, helium-oxygen can also be considered.

So what's the rest of the story?

 

[Gimlet]

Intubated.

Agree with above but the patient is on the floor, not intubated.

uhhhh...

 

[Planktonmd]

Agree with above but the patient is on the floor, not intubated. Anticholinergics haven't been shown to be helpful in adults (only children)

😕
Why do you think Asthmatics are given ipratropium?

The dose for magnesium should be higher though (RCT indicates 2gm is effective). ?

You can't give magnesium too fast so how about you give 1 gram to see if you can break the the acute episode and then you give more as needed?

There's a myth that steriods don't act sooner than 6 hours, but that was before we recognized membrane-associated steroid receptors (that act independent of transcription). Either way steroids don't act fast but should be give at the soonest opportunity.?

Correct! the soonest opportunity after the patient stops trying to die and when you don't have anything better to do like give epinephrine for example.

Once the patient is intubated,

I thought the patient is intubated!

helium-oxygen can also be considered.

😀
OK, but the patient is "coding" and you might not have enough time to find a helium cylinder sitting around.

 

[proman]

Damn. Missed the intubated part.

Anticholinergics have a minimal benefit in adults. The Cochrane Collaboration is currently doing a review on this. Bronchospasm from asthma is a different disease than bronchospasm from COPD. They are fairly benign drugs, that in the scenario, have failed. I doubt atropine will accomplish much more and would focus my efforts on getting IV epi on board (or now down the tube). And to an ICU.