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The Commonwealth of Massachusetts
Executive Office of Health and Human Services
State EMS Medical Director
Basic and Intermediate Albuterol Treatment for Known Asthmatics
As part of the revised Statewide Treatment Protocols, version 5.5, effective November 1, 2003,
ambulance services statewide will have the option of having their Basic and Intermediate EMTs provide
medication to known asthmatics who meet the eligibility criteria outlined in the Boston EMS Assisted
Albuterol Program. In order to do this, your service must meet the following conditions:
1. The ambulance service’s affiliate hospital Medical Director must have authorized
Basic and/or Intermediate EMTs to utilize this protocol while employed by the ambulance
2. The ambulance service must
comply with the Drug Control Program
3. If it does not already have an affiliation agreement for medical control, the ambulance service
have a current signed Memorandum of Agreement
(MOA) with their affiliate hospital
for medical control and medical direction that addresses participation in this program.
4. The ambulance service must
provide training to its EMTs as set out in the EMS Assisted
Albuterol Program document, dated August 2003. (Attached)
5. The ambulance service must
provide regular QA/QI, collect data and perform chart reviews
as set out in the EMS Assisted Albuterol Program document, and submit reports to the Department upon request.
Failure to comply with any of these conditions disqualifies your service from participation in this program. For any questions regarding this program, please contact OEMS Clinical Coordinator Tom Quail, RN, at (617) 284-8330.
ASSISTIVE ALBUTEROL PROGRAM
NOTE: YOUR MEDICAL DIRECTOR MUST HAVE AUTHORIZED YOU AS
AN EMT TO UTILIZE THIS PROTOCOL.
The EMT must be properly trained and authorized to perform the following
treatment as outlined in the attached letter from the Department.
Massachusetts is beginning a statewide service option program in BLS assisted nebulized medication for asthmatics in crisis. EMTs functioning at the Basic and Intermediate level of certification, will be able to assist patients with a nebulized bronchodilator, albuterol sulfate, in the course of their evaluation and treatment.
The population will be restricted to those patients between the ages of 6 months thru 45 years who have no cardiac history and who have a medical diagnosis of asthma. Additionally, they must have a prescribed beta
agonist which they would normally use during an asthma attack. They may normally self-administer this medication via either nebulizer or inhaler.
BLS ambulances participating in this program must be stocked with both adult and pediatric nebulizer setups and will carry pre-packaged unit doses of albuterol sulfate. A patient eligibility checklist will be stored with the albuterol unit doses for reference onsite during calls. Clear criteria are established for patient eligibility with assistive medication and the various subjects surrounding this issue. This includes dosage, documentation, hospital notification and rendezvous with ALS units.
Once fully implemented, this program should significantly lower the number of asthmatics who are suffering an exacerbation of their disease who do NOT receive appropriate nebulizer therapy while enroute to the hospital. The program will have several critical areas including: ensuring that the patient is a member of the “eligible” population; a good physical assessment; adequate notification of the receiving facility; the ALS/BLS interface; and continual reassessment of the patient during transport.
ASSISTIVE ALBUTEROL PROGRAM OUTLINE
The concept of “assisting” with medication
GENERAL REVIEW OF RESPIRATORY PHYSIOLOGY 1.
Triad of, bronchoconstriction, inflammation and mucous plugging
Diseases that may be confused with asthma 1.
Epiglottitis and upper airway obstruction
RESPIRATORY DISTRESS VERSUS RESPIRATORY FAILURE 1.
Maintenance therapy versus acute therapy
agonists (selective versus non-selective)
“ASSISTIVE” NEBULIZER THERAPY PROTOCOL AT BOSTON EMS
Practical demonstration/practice setting up nebulizer
PROTOCOL REGARDING STORAGE, RESTOCK AND RESUPPLY
Evaluation of patients with respiratory compromise
A patient with respiratory compromise will often provide many clinical clues that can be used by prehospital personal to make an accurate assessment of respiratory status.
Clues to respiratory compromise can be found by systematically examining the patient while looking at the following:
1) Pay attention to the patient’s posture when first meeting them. Is the patient positioned in such a
way as to assist in the mechanics of respiration? Is the patient sitting/leaning forward? Does the patient have difficulty lying down or sitting back as evidenced by increasing discomfort or dyspnea?
A patient with severe dyspnea may only be able to speak in short phrases rather than in complete sentences.
A patient in severe distress may be unable to speak at all.
3) Look at the overall appearance of the patient:
The mood that the patient is displaying often indicates how they are doing.
Does the patient look scared? Does the patient look anxious? Does the patient look tired? Does the patient look uncomfortable? If a child or infant, is the patient distractable from their present condition?
Realize that all of these may be signs of underlying hypoxia.
4) Physical examination. Performed systematically as per standard procedures.
• see diagram showing signs of respiratory distress/respiratory failure -
of the chest may provide clues about underlying lung pathology. Patients with COPD
will often have a barrel chest appearance (increased anterior posterior diameter). The use of
accessory muscles of the neck, chest and abdomen can assist patients in the mechanics of
respiration, allowing for increased air exchange during respiratory compromise.
of the rib cage during inhalation may show evidence of unequal expansion (potential
probably the most important aspect of the chest exam. Lung sounds are essential
to a complete respiratory exam and should be performed in a thorough and consistent manner.
Listen for the presence of breath sounds
• Determine the equality of breath sounds. • always listen in at least four different locations both anteriorly and posteriorly, while *
comparing the right and left sides together.
• At minimum, listen under clavicles at midclavicular line and at bases at the
LISTEN FOR ANY ADVENTITIOUS (ABNORMAL) BREATH SOUNDS:
are high pitched, whistling sounds made by air flowing through a constricted airway.
Diffuse wheezing on exhalation is heard with asthmatic patients but is also found in other conditions
that will be described later .realize that the absence of wheezing may indicate severe respiratory
distress/failure considering that a patient with severe airway compromise may not be moving enough
air for wheezing to be heard.
are rattling noises in the throat or bronchi, often due to partial obstruction of the large
airways by mucous.
are fine, moist sounds that may sound like crackling or bubbling in quality, associated with
fluid in the smaller airways.
NOTE: Current DOT EMT-B Curriculum does NOT teach these three breath sounds.
Implementing this program would require your service to do so.
GENERAL REVIEW OF RESPIRATORY PHYSIOLOGY
Anatomy of respiratory system
(Use Diagram to review anatomical relationships described below)
The primary passageway for air to enter and leave the respiratory system.
A secondary pathway for air to move through the respiratory system.
. A passageway for food.
a passageway that connects the pharynx and trachea. The larynx is covered by the
thyroid and cricoid cartilage and contains the voice box.
a cartilaginous ringed structure that connects the larynx With the lungs, the carina is
the point of bifurcation that divides the trachea into right and left mainstem bronchi.
.the branching that occurs from the mainstem bronchi all the way down to the
microscopic air sacs (alveoli) that are responsible for the exchange of oxygen and carbon dioxide.
spongy, elastic tissue containing alveoli. The right lung can be divided into three lobes
(upper, middle and lower), the left lung is divided into two (upper and lower).
.muscles that are attached to the ribs that are responsible for contraction
During inspiration and relaxation during expiration.
.a dome shaped muscle forming the floor of the pleural cavities that has both voluntary
and autonomic function. Contraction of the diaphragm causes the thorax to expand by forming a
slight vacuum within the chest.
Mechanics of respiration
Breathing is accomplished through pressure changes in the lungs which are brought about by activity of the respiratory muscles (both the intercostal muscles and diaphragm) .
Inhalation is an active
process that requires muscular contraction. As the volume of the thoracic
cavity increases, the pressure drops, allowing air to rush into the lungs.
The diaphragm flattening and descending, thus increasing the vertical dimensions of the thorax.
The intercostal muscles contracting causing the ribs and sternum to move upward and outward, increasing the horizontal dimensions of the chest cavity.
Exhalation is a passive
process that occurs at the end of inspiration as the respiratory muscles
relax, the chest wall recoils, intrathoracic pressure rises, and air is expelled from the lungs.
Accessory muscles are used to aid a patient in re spiratory distress. The neck, chest and
abdominal muscles are primarily involved.
PATHOPHYSIOLOGY OF ASTHMA
Asthma is a chronic respiratory disease where there is reversible airflow obstruction, associated with a state of increased responsiveness of the tracheobronchial tree to many different stimuli.
Asthma may be divided into three components:
1). bronchial smooth muscle contraction is the rapidly reversible component of airway obstruction that defines asthma.
3). inflammatory changes, that may last for weeks once stimulated.
The extreme sensitivity of the airways to physiologic, chemical and pharmacological stimuli is felt to be a hallmark of asthma.
Traditionally, the triggers of asthma that are responsible for causing this hyperactivity have been classified as either intrinsic or extrinsic in nature.
Extrinsic asthma is said to be “allergic” or immunologic in origin.
Intrinsic asthma exists when no obvious extrinsic causes can be found.
A model that incorporates both intrinsic and extrinsic components is probably more representative of the disease process than having two separate classes of asthmatics.
Many agents have been found to cause asthma either through immunological mechanisms or through direct irritant effects.
• immunological reaction (exposure to antigen with mediator release). • viral respiratory infections of the upper and lower respiratory tract. • changes in temperature and humidity (especially cold air).
• pollutants, dusts, fumes and other irritants
• certain drugs (aspirin, nsaids, beta
• strong emotions, - laughing, coughing
• (gastroesophageal reflux disease) gerd
DISEASES AND CONDITIONS THAT MIMIC ASTHMA.
• Aspiration of foreign body or gastric acid.
• Bronchogenic carcinoma with endobronchial obstruction • Bronchiolitis • Multiple pulmonary emboli (rare)
Remember “all that wheezes is not asthma.”
The patient’s history as well as their age will often provide the information that is necessary to make a correct differential diagnosis.
It is essential to confirm that the patient has bronchial asthma before you may assist them in nebulized beta
agonist therapy. The patient will usually be able to acknowledge this fact, however, if it is not
clear that the patient is taking beta agonists for asthma therapy assisting the patient with
nebulized therapy is contraindicated
Respiratory distress verses respiratory failure
Is when a patient has begun to show clinical signs and symptoms suggestive of inadequate blood oxygenation.
• use of accessory muscles in the neck and abdomen
• retraction of the intercostal and suprasternal spaces during inhalation.
Is either apnea (failure of respirations), or the reduction of normal breathing to the point where oxygen intake is not sufficient to support life.
Reassessment of the patient with respiratory compromise is essential so that proper medical therapy may be provided. Patients in respiratory failure will require ventilatory assistance and often endotracheal intubation.
Therapy is directed toward all three components
of the disease: bronchoconstriction, inflammation
and mucous formation.
However, the focus of acute therapy is centered around bronchodilation of smooth muscle because of the rapid effects that can be obtained.
The airflow obstruction that is due to mucous plugging and the inflammatory changes seen in the bronchial wall does not usually resolve for days or weeks. Therapy to treat both of these components is also initiated in the emergency department. The results of these interventions, Including hydration and corticosteroids, are not usually seen for several hours.
Involves two different regimens of medications:
Patients take these medications to prevent
an exacerbation of asthma.
Are used during
an asthma exacerbation. Bronchodilators are used initially due to their rapid effect. Eventually anti-inflammatory agents may be needed with adequate hydration necessary to thin mucous secretions.
-agonists, are used for both acute and maintenance therapy.
Other drugs are only used exclusively in maintenance therapy such as, cromolyn sodium (mast cell stabilizer) and are of no use in acute therapy.
It is important to determine not only the medications that a patient may be taking to control their disease but also the frequency of use. You should ask them whether or not they take them on a daily or prn (as needed) basis.
PHARMACOLOGY OF ASTHMA
-agonists: Are considered the first line therapy in the treatment of acute asthma. The medication binds primarily to two different types of receptors (beta
-1 and beta
-2 receptors Are found predominately in the lung and blood vessels and cause bronchodilation and vasodilation, respectively, when stimulated.
-1 receptors are found predominately in the heart and may cause tachycardia and increased contractility when stimulated.
can be divided into selective (binding to beta
-2 receptors >>beta
-1 receptors) And nonselective medications:
Selective medications are manufactured to have their primary effect on lung tissue with minimal cardiovascular side effects.
Aerosol therapy with beta
adrenergic drugs allows local administration with minimal systemic absorption and minimal side effects. Some of these include:
• albuterol sulfate (airet, proventil, ventolin)
• isoetharine (bronkometer, bronkosol)
• isoproterenol hydrochloride (isuprel)
• metaproterenol sulfate (alupent, metaprel)
The most common side effect of beta
adrenergic medications is skeletal muscle tremor. Patients may also experience nervousness, anxiety, insomnia, headache, hyperglycemia, nausea and vomiting, palpitations, tachycardia and hypertension.
Is a nonselective beta
agonist (also has alpha receptor effects that can cause peripheral vasoconstriction) that is administered subcutaneously in the treatment of severe asthma.
(Similar to above) although with more pronounced cardiovascular side effects including tachycardia, hypertension and arrhythmia formation.
A bronchodilator that has fallen out of favor in the past few years as a first line medication in the treatment of asthma, replaced with nebulized and meter dose inhaler beta
agonist therapy which provide greater bronchodilation. Today, the drug is usually prescribed when a patient is hospitalized and requires multi-drug therapy.
The toxicity of theophylline is well described, due to the drug having a narrow therapeutic window (there is a small range of serum drug levels between the desirable (therapeutic) level and that which is toxic). This is why the drug is no longer used regularly as a first line agent.
The importance of using steroids in severe asthma has been well documented. They are of utmost
importance in reversing a severe asthma exacerbation as they reduce the inflammatory response, rather than just temporarily causing bronchodilation. There is a delay of six to eight hours following iv administration before clinical effects are seen. They are generally reserved for patients that have been on them in the past and in any case with a severe presentation. Patients will often be put on an oral prednisone taper(usually less than 14 days) immediately following an acute presentation to prevent a recurrence considering that the patient’s lung remains hypersensitive to stimuli.
Anti-cholinergic (ipratropium bromide (atrovent)):
Have been used in the treatment of asthma. These drugs are responsible for antagonizing the vagal nerve component of bronchoconstriction that is felt to exist during asthma.
Reduces the reduce of histamine from MAST cells, (thought to be involved in the inflammatory component of asthma). It is used chronically to prevent the exacerbation of asthma. Cromolyn is NOT a bronchodilator and is of no use in the termination of an acute asthma attack.
BLS ASSISTIVE NEBULIZER ELIGIBILITY CHECKLIST
1. Does the patient have a diagnosis of asthma?
, proceed to next question.
IF NO, PATIENT IS NOT ELIGIBLE
2. Is the patient older than six months but younger than 46?
, proceed to the next question.
IF NO, PATIENT IS NOT ELIGIBLE.
3. Does the patient have a known history of cardiac disease (past MI or angina)?
, proceed to the next question.
IF YES, PATIENT IS NOT ELIGIBLE.
4. Does the patient have a current
prescription for an inhaler or nebulizer to be used when they
are having an attack? (This does NOT include over-the-counter medications like Primatene
mist. It also does NOT include inhaled steroids like Beclovent.)
ELIGIBLE MEDICATIONS (Rescue Meds)
albuterol sulfate (Airet, Proventil, Ventolin)
metaproterenol sulfate (Alupent, Metaprel)
INELIGIBLE MEDICATIONS (Maintenance Meds)
beclamethosone dipropianate (Beclovent, Beconase, Vancenase, Vanceril)
dexamethosone sodium (Decadron Respihaler)
, proceed to the next question
If no, then the patient is NOT
5. Ask the patient, “Would you like us to ASSIST you in taking the same type of medication that
you take when you have an asthma attack?”
proceed to the next step
NOTE: The EMT will use their own medication (neb and oxygen) because the patient’s
medication may be ineffective or out of date.
, treat the patient appropriately and transport
6. A. If the patient is between 6 months and 2 years of age, assemble the appropriate nebulizer
and fill it with the full unit dose of albuterol sulfate and full contents of a saline “squirt.” (Dose for Patient Care Report = 2.5 mg in 6 ml saline)
B. If the patient is older than 2 but younger than 46, assemble the appropriately sized nebulizer and fill the medication reservoir with 1 (one) unit dose of albuterol sulfate. Place the mask on the patients face and run the oxygen at a minimum of 6-8 lpm (enough to mist up the mask). (Dose for documentation: 2.5 mg in 3 ml saline)
7. Package and transport the patient appropriately. Notify receiving hospital
Does the patient have a diagnosis of asthma?
The intent of this question is to confirm that a patient is truly an asthmatic. The patient should be under the care of a physician who has prescribed them medications for their asthma. Patients who say “I had asthma as a child” or “I think I have asthma” or “someone told me they think I have asthma” would not be confirmed as having a diagnosis of asthma. Most patients will be quite clear in their answer. If there is a doubt that they truly have asthma, assisting them with medication is not appropriate.
Is the patient older than six months but younger than 46?
To be specific, between six months and zero days thru 45 years 364 days.
Does the patient have a known history of cardiac disease?
If the patient has a history of myocardial infarction or chest pain which has been diagnosed as angina, they are not eligible. This can usually be determined by asking “Have you ever been told you have had a heart attack?” and “Have you ever been prescribed nitroglycerin for your chest pain.”As it is with all of the criteria, if there is a doubt about eligibility, the patient should be treated appropriately but not given assistance with inhaled medication.
Does the patient have a current prescription for an inhaler or nebulizer to be used when
The emphasis here is on current
prescription. Words like “I’ve had one in the past” or “I used to
take Ventolin when I was a kid” or “I’ve used my brother’s inhaler before” should be clear markers
The second part of this question is key in that it helps distinguish between inhalers that are used in
acute episodes versus those used routinely every day. If at all possible, you should confirm the
medication either visually by looking at the inhaler or nebulizer medication or by questioning the
patient and then confirming it against the Eligible Medication
list. If the patient states that they do
have medication that they take either via nebulizer or inhaler when they have an attack, it can be
assumed that the patient is using one of the drugs on the Eligible
list, even if you cannot verify the
medication either visually or verbally.
The question of whether they take the medication via inhaler or nebulizer is moot. If they take the
medication for acute
episodes it meets our criteria for eligibility.
5. Ask the patient, “Would you like us to ASSIST you in taking the same type of medication that you
If at all possible, this question should be asked exactly as written above. If there is a language barrier or comprehension gap, you may rephrase it but the intent is to ask if they would like us to assist them in taking the same type of medication they use during an asthma attack. It should be reiterated that if you doubt the patient takes either an inhaler or nebulizer for acute events, the patient does not meet the eligibility criteria.
Once you have established that the patient meets all of the criteria, the next step is administration of the medication.
ages 6 months to 2 years— Pediatric Dose 2.5 mg of Albuterol Sulfate in 6 ml of Normal Saline
If the patient is between the ages of 6 months and 2 years old, the concentration of the medication is diluted by mixing the contents of one unit dose vial with the contents of one plastic saline squeeze vial This reduces the concentration of the drug but doubles the volume.
Some young children may not tolerate the mask over their face. Disconnect the mask from the nebulizer and have the parent hold the nebulizer and direct the vaporizer cloud toward the patients face. Most parents will know the best way to give their child nebulized medication so do not be reluctant to ask them which is the best way!
Ages 2 years to 46 years old. Adult dose 2.5 mg of Albuterol Sulfate in 3l of Normal Saline (pre-
The medication will be in either a unit dose plastic squeeze vial or a screw-top unit dose container.
Once you assemble the nebulizer, you open the medication reservoir and place the contents of the entire
vial into it. Assist the patient in placing the mask upon their face and run the liter flow on the
oxygen at a rate which is high enough to create a mist within the mask. This is a minimum of 6-8
At this point, the patient should be packaged and moved to the vehicle for transport if this has not already been done
ALS should have been dispatched per protocol.
of the patient looking specifically at respiratory effort and breath sounds is critical
once assistive medication has been instituted. You should look for changes in respiratory effort,
tidal volume, wheezing, and level of consciousness. If possible, ask the patient to indicate whether
they are getting better or worse. Changes in patient condition should be relayed to the staff at the
receiving facility and clearly documented on the PCR.
NOTE: Pulse oximetry is highly recommend to be used if available before, during & after
patient treatment, provided there is no delay in treatment.
PROTOCOL FOR ASSEMBLING AND FILLING A NEBULIZER
Choose the appropriate size nebulizer mask and setup.
Unlock the BLS medication box and remove a unit dose of albuterol sulfate. If the patient is between 6 months and two years of age, also remove 1 orange saline squeeze container.
Unscrew the medication reservoir of the nebulizer setup and place the bottom
half on a hard flat
Open the unit dose vial and empty the entire
contents into the bottom half of the nebulizer
medication reservoir. If the patient is between 6 months and two years of age, open the orange
saline squeeze container and empty its entire contents into the reservoir as well.
Screw the bottom half and top half of the medication reservoir together taking care to keep it as upright as possible.
Attach the oxygen supply tubing contained within the nebulizer setup to the nipple on the bottom of the medication reservoir.
Attach the other end of the oxygen supply tubing to a oxygen source.
Turn the liter flow on and run at a rate high enough to create a mist within the contents of the mask. This is a minimum of 6 lpm. (Running the liter flow at too low a setting will not create a mist. Too high a liter flow setting could cause the supply tubing to disconnect from either end because of the high pressures.)
Assist the patient in placing the mask over his/her face. Snug the mask to the face and instruct the patient to take deep slow breaths if possible.
the patient’s condition with particular emphasis on respiratory effort and breath
sounds. Ask the patient whether he or she subjectively feels better. Be particularly alert for
signs of increasing respiratory distress and impending respiratory failure. Be prepared to assist
patient’s ventilations if necessary and notify the receiving facility of any marked changes in
STORAGE, RESTOCK AND RESUPPLY PROTOCOL
The albuterol unit doses shall be stored in the BLS medication box which hold the EpiPen Auto injector. There shall be no exceptions to this.
The par levels for unit doses per vehicle shall be a MINIMUM of one and a MAXIMUM of four. When a vehicle reaches the minimum par level, they must restock their ambulance per service policy
The par levels for nebulizer setups shall be:
of one and a MAXIMUM
B. Pediatric - a MINIMUM
of one and a MAXIMUM
• When a vehicle reaches the minimum par level of either setup, they must restock their
1. The narrative portion of the PCR must contain certain key words or phrases.
Patient uses inhaler in times of crisis. If at all possible, the name of the inhaler should be listed under “Meds” on the PCR.
The physical exam must include the breath sounds and respiratory effort. Baseline vital signs should be recorded.
Under the Tx portion, it should be clearly documented on the PCR that the patient was asked if he would like assistive medication and that the patient responded in the affirmative.
Address patient refusal and/or consent issues.
Under the Tx portion, it should be documented that assistive nebulizer therapy was initiated and the time it was initiated.
It should be indicated whether ALS evaluated the patient or was cancelled and, if so, WHEN they were cancelled.
The reassessment of the patient and the findings should be documented clearly on the PCR.
It should be clearly indicated whether the receiving hospital was notified.
On the trip record document “Neb” written in with the appropriate EMT identification number, initials, or name. At the section for “Oxygen” indicate that a nebulizer was used and at what liter flow.
For PARAMEDIC/ADVANCED LIFE SUPPORT, standard documentation.
For ages 2 - 45, the time of therapy, the drug (albuterol sulfate or albuterol), the dose which is 2.5
mg in 3 ml saline
and the route is “neb” or “nebulizer”
For ages 6 months to 2 years, the time of therapy, the drug (albuterol sulfate or albuterol), the dose
which is 2.5 mg in 6 ml saline
and the route is “neb” or “nebulizer.”
KEY POINTS TO REMEMBER
The patient must be bronchoconstricted!!!
There must be a medical diagnosis of asthma!!!
They must be older than 6 months but younger than 46 years
There is no history of cardiac disease (MI or chest pain)
The patient takes a prescribed inhaled medication EMERGENTLY
The inhaled medication is from the Eligible List
The patient indicates he wants to be assisted with similar type medication
Receiving hospital is notified when appropriate
ALS intercept must be arranged for & confirmed whenever possible.
Do not delay transport.
REASSESSMENT REASSESSMENT REASSESSMENT
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RLUH ICU: Guidelines for the Use of Steroids In ARDS in the ITU GUIDELINES FOR THE USE OF STEROIDS IN ARDS IN THE ITU Various regimens are described in the literature: 1. • Treatment commenced after 15 +/- 7.5 days • Methylprednisolone 200 mg bolus then: • 2–3 mgkg-1day-1 until extubated then taper over 6 weeks Refs: Meduri et al. Chest 1994; 105: 1516–1527 See also letter in