1

IntroductionIntroduction

• 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.

• 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.

2

Introduction (cont.)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 EMTs.

3

Mortality from asthma is increasing worldwide

From 1980 - 1987, the death rate From 1980 - 1987, the death rate has increased by 31% in the United has increased by 31% in the United

States. 5,000 deaths per year.States. 5,000 deaths per year.

4

Many studies have shown

The efficacy and SAFETY of albuterol in the treatment of bronchospasm associated with asthma.

5

An expanded scope of practice for EMTs

Could provide benefits to the population of asthmatics in New

York City

6

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

7

Inclusion CriteriaInclusion 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.

8

Exclusion CriteriaExclusion Criteria

• Patients with a history of hypersensitivity to albuterol sulfate.

• Patients exhibiting signs of respiratory failure (a patient requiring ventilations).

9

Adult Respiratory Failure

• Decreased level of consciousness

• Too dyspneic to speak

• Cyanosis (despite oxygen therapy)

• Diminished breath sounds

• Patient requires assisted ventilations

10

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.

11

Differential Diagnosis of Bronchospasm

• COPD

• Foreign body obstruction

• Pulmonary Embolus

• Anaphylactic reaction

• Pulmonary Edema

• Asthma

12

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

13

The Lungs

14

The Lower Airway

15

Triggers of Asthma Attacks

• Allergies

• Infection

• Stress

• Temperature changes

• Seasonal changes

16

Signs and Symptoms

• 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)

17

Respiratory Muscle Fatigue

• Muscles are overworked to compensate for problem.

• Increased work of breathing

• Can lead to exhaustion and respiratory failure.

18

Assessment of The Asthma Patient

19

Assessment of the Asthmatic

• Chief complaint

• History of present illness

• Past medical history

20

History of Present Illness

• 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

21

Past Medical History

• 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.

22

Note: Do not delay treatment to solicit a patient’s medical history

(except: asthma,allergies and cardiac history.)

23

Physical Examination

• 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

24

Physical Examination (cont.)

• Borg Scale (0 - 10)

• Peak flow

• Height (you may ask patient)

25

26

Peak Flow Meter

27

Auscultation of Breath Sounds

• General requirements for successful evaluation:

• Patience

• Effective technique

• Good hearing

• Knowledge of sounds

28

Physical Examination (cont.)

• Assessing lung sounds• Rales

• Rhonchi

• Stridor

• Wheezing

29

Lung Sounds Found In Common Emergency Conditions

• C.O.P.D.– Diminished– Wheezes– Prolonged expiratory phase

• Pneumonia– Rales (usually in one area)

30

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

31

Wheezes

• High pitched, continuous sounds

• Occur on inspiration or expiration

• Result of narrowed bronchioles

32

Wheezing Assessment

• No Wheezing

• Wheezing (audible with stethoscope)

• Wheezing (audible without scope)

• Poor air exchange (diminished lung sounds)

33

Absent or Diminished Sounds

• Pneumothorax

• Hemothorax

• Obesity

• Hypoventilation

• Fluid or pus in pleura or lung

• COPD or Asthma with poor airflow

34

Stethoscope Placement

35

Technique

• 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

36

Technique

• Have the patient open mouth and take deep breaths.

• Avoid hyperventilation.

• Listen at each location and note abnormalities.

37

Albuterol Sulfate Ampules

38

Pharmacology: Albuterol Sulfate• Actions

– Bronchodilator

• Minimal side effects• Nervousness • Palpitations

• Dizziness • Drowsiness

• Flushing • Chest discomfort

• Tachycardia • Muscle cramps

• Dry mouth • Insomnia

• Tremors • Weakness

39

Indications for Project Use

• Relief of broncospasm due to exacerbation of asthma.

Use with caution for patients with:• Previous M.I.

• C.H.F. You must contact

• Angina Medical Control

• Arrhythmias

40

Contraindications

• Patients with known hypersensitivity to the medication or its components.

• Patients in respiratory failure(those patients requiring ventilatory assistance)

41

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.

42

5 rights of Medication Administration

• Right Patient

• Right Drug (beware look alikes)

• Right Dosage

• Right Route

• Right Time

43

Check 3 Times For:

• Expiration Date

• Discoloration and Clarity

• Particulate matter

44

Administration (cont.)

• 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

45

Nebulizer

46

Assembled Nebulizer

47

Assembled Nebulizer and Oxygen Tubing

48

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

49

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

50

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

51

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.

52

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

53

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

54

Administrative

• Restocking of equipment

• Restocking of albuterol– Paramedics have been instructed not to re -

supply BLS units. Follow local procedure.