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Introduction
• In 1996, asthma was the leading cause of
hospitalizations in New York City for
children (up to the age of 14 ).
• In 1995, asthma hospitalizations for
children of the same age group were 3
times the national average and 5 times
the state average.
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Introduction (cont.)
• In New York City, EMTs & Paramedics
treat approximately 50,000 asthmatics each
year.
• While these patients benefit from
bronchodilator therapy, the availability of
ALS response units cannot always be
assured.
• As a result, these patients are treated by
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EMTs.
Mortality from asthma is
increasing worldwide
From 1980 - 1987, the death rate
has increased by 31% in the United
States. 5,000 deaths per year.
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Many studies have shown
The efficacy and SAFETY of
albuterol in the treatment of
bronchospasm associated with
asthma.
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An expanded scope of practice for EMTs
Could provide benefits to the
population of asthmatics in New York
City
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May 1, 1998 - 2 new call types
were implemented
• ASTHMP - for patients under 15 years old
• ASTHMA - for patients 15 years of age or
older
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Inclusion Criteria
• Patients between the ages of 1 and 65 years
old (with no ALS immediately available).
• Patients complaining of difficulty breathing
secondary to an exacerbation of their
previously diagnosed asthma.
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Exclusion Criteria
• Patients with a history of hypersensitivity to
albuterol sulfate.
• Patients exhibiting signs of respiratory
failure (a patient requiring ventilations).
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Adult Respiratory Failure
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Decreased level of consciousness
Too dyspneic to speak
Cyanosis (despite oxygen therapy)
Diminished breath sounds
Patient requires assisted ventilations
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Pediatric Respiratory
Failure
• Ineffective respiratory effort with central
cyanosis, agitation or lethargy, severe
dyspnea or labored breathing, bobbing or
grunting and marked intercostal &
parasternal retractions.
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Differential Diagnosis of
Bronchospasm
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COPD
Foreign body obstruction
Pulmonary Embolus
Anaphylactic reaction
Pulmonary Edema
Asthma
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Pathology of Asthma
• Reversible smooth muscle spasm of the
airway associated with hypersensitivity of
the airway to different stimuli. Primarily an
inflammatory process.
• Smooth muscle contractions
• Mucosal edema
• Mucous plugging
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The Lungs
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The Lower Airway
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Triggers of Asthma Attacks
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Allergies
Infection
Stress
Temperature changes
Seasonal changes
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Signs and Symptoms
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Dyspnea
Wheezing
Tachypnea
Tachycardia
Cyanosis
Cough
• Accessory muscle use
• Inability to speak…..
in complete… sentences.
• Anxiety (hypoxia)
• Prolonged expiratory phase
• Tripod positioning
• Nasal Flaring (infants)
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Respiratory Muscle Fatigue
• Muscles are overworked to compensate for
problem.
• Increased work of breathing
• Can lead to exhaustion and respiratory
failure.
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Assessment of The Asthma
Patient
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Assessment of the Asthmatic
• Chief complaint
• History of present illness
• Past medical history
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History of Present Illness
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How long
Events leading up to…
How severe (Borg Scale)
Aggravating / Alleviating factors
Other complaints
Steroid use in last 24 hours (p.o. / inhaled)
Other medications
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Past Medical History
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Confirm asthma history
Other medical conditions (cardiac)
E.D. visits for asthma in the last 12 months
Hospital admissions for asthma in last 12
months
• Previously intubated due to asthma?
• Allergies to medications, etc.
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Note: Do not delay treatment to
solicit a patient’s medical history
(except: asthma,allergies and
cardiac history.)
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Physical Examination
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Respiratory distress vs. Respiratory failure
Posturing (tripod positioning)
Pursed lip breathing
Vital signs
Skin color, temperature and moisture
Ability to speak... in complete... sentences
Accessory muscle use
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Physical Examination (cont.)
• Borg Scale (0 - 10)
• Peak flow
• Height (you may ask patient)
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Peak Flow Meter
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Auscultation of Breath Sounds
• General requirements for successful
evaluation:
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Patience
Effective technique
Good hearing
Knowledge of sounds
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Physical Examination (cont.)
• Assessing lung sounds
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Rales
Rhonchi
Stridor
Wheezing
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Lung Sounds Found In Common
Emergency Conditions
• C.O.P.D.
– Diminished
– Wheezes
– Prolonged expiratory phase
• Pneumonia
– Rales (usually in one area)
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Lung Sounds Found In Common
Emergency Conditions
• Pulmonary Edema
– Diminished Sounds
– Rales (usually bilateral)
• Asthma
– Diminished Sounds (may be on one side)
– Wheezes
– Prolonged expiratory phase
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Wheezes
• High pitched, continuous sounds
• Occur on inspiration or expiration
• Result of narrowed bronchioles
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Wheezing Assessment
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No Wheezing
Wheezing (audible with stethoscope)
Wheezing (audible without scope)
Poor air exchange (diminished lung
sounds)
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Absent or Diminished Sounds
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Pneumothorax
Hemothorax
Obesity
Hypoventilation
Fluid or pus in pleura or lung
COPD or Asthma with poor airflow
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Stethoscope Placement
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Technique
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Sit patient up
May not be possible to auscultate all areas
Place diaphragm firmly on chest wall
Avoid extraneous noise
Avoid prolonged examination of the chest
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Technique
• Have the patient open mouth and take deep
breaths.
• Avoid hyperventilation.
• Listen at each location and note
abnormalities.
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Albuterol Sulfate Ampules
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Pharmacology: Albuterol Sulfate
• Actions
– Bronchodilator
• Minimal side effects
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Nervousness
Dizziness
Flushing
Tachycardia
Dry mouth
Tremors
• Palpitations
• Drowsiness
• Chest discomfort
• Muscle cramps
• Insomnia
• Weakness
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Indications for Project Use
• Relief of broncospasm due to exacerbation
of asthma.
Use with caution for patients with:
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Previous M.I.
C.H.F.
Angina
Arrhythmias
You must contact
Medical Control
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Contraindications
• Patients with known hypersensitivity to the
medication or its components.
• Patients in respiratory failure
(those patients requiring ventilatory assistance)
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Dosage
• One unit dose, 3.0 cc or 0.083%
Via nebulizer at 6 liters per minute or at
a flow rate that will deliver the
medication over 5 to 15 minutes.
• Dose may be repeated if the symptoms
persist for a total of 2 doses.
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5 rights of Medication
Administration
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Right Patient
Right Drug (beware look alikes)
Right Dosage
Right Route
Right Time
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Check 3 Times For:
• Expiration Date
• Discoloration and Clarity
• Particulate matter
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Administration (cont.)
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Assemble nebulizer
Add medication
Attach to oxygen regulator
Set flow meter to 6 lpm
Instruct patient on use
– inform adult patient
– modify delivery for very young patients
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Nebulizer
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Assembled Nebulizer
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Assembled Nebulizer and
Oxygen Tubing
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Treatment of Asthma Patient
• Assess breathing
• Administer oxygen via non - rebreather
or assist ventilations
• Monitor Breathing
• Do not permit physical activity
• Place patient in position of comfort
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Assess and Document prior to
administration of albuterol
• Patient is between 1 and 65 years of age
• Dyspnea is secondary to previously
diagnosed asthma
• Vital signs
• Ability to speak… in complete... sentences
• Accessory muscle use
• Wheezing assessment
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Assess and Document prior to
administration of albuterol (cont.)
• Borg scale (0 - 10)
• Peak flow
• Contact medical control if patient has
pertinent cardiac history
• “The 5 rights” of medication administration
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Treatment (cont.)
• Administer albuterol sulfate (one unit dose)
via nebulizer (6 lpm)
• Begin transport
– Do not delay transport to administer medication
• If symptoms persist, give 2nd dose
• Upon transfer of patient, reassess and
document as before.
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Treatment (cont.)
• Medical control MUST be contacted for any
patient who refuses medical assistance or
transport.
• Request ALS if the patient is in respiratory
failure
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Documentation
• ACR : All pertinent data should be recorded
in the “Comments” and “Treatment /
Response” sections
• PCR : All pertinent data should be recorded
in the “Subjective & Objective Physical
Assessment” sections as well as the
“Comments & Treatment Given” sections
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Administrative
• Restocking of equipment
• Restocking of albuterol
– Paramedics have been instructed not to re supply BLS units. Follow local procedure.
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