Is there a pharmacological benefit to administering dexamethasone PO vs IV/IM or is it the preferred route simply to avoid unnecessary sharp use? 

If my asthmatic patient has an anaphylactic reaction do they also get dexamethasone? 

Now that the PCP scope includes utilizing an SGA in patients outside of cardiac arrest, can salbutamol be administered via SGA utilizing the airway adaptor? This would be the same piece of equipment allowing MDI of Salbutamol for BVM, CPAP, CPAP, ETT and SGA.

In regards to Dex administration being contraindicated for patients currently on parenteral or PO steroids, can we get some more clarification on what we are referring to specifically – is it basically all steroids? Most patients with COPD tend to be on steroid puffers which presumably would make those patients not able to receive dexamethasone?

Should we be piggy backing dexamethson every time we give ventolin if the pt has a history of copd or asthma or 20 pack history.

Does Vaping or marijuana use count towards the 20 pack-year history of smoking.

Does the patient need to be actively smoking to count for the Condition of 20 pack-year history in order to administer Dexamethasone?

The vial of dexamethasone does not say that it can be given orally. Is it safe to give this route?

hello when treating a pt with adenosine the contra indications are active bronchial constriction on exam, the companion document also states that adenosine can cause bronchial constriction in asthmatic pts. so may question is … is an asthmatic pt contraindicated for adenosine tx or is more of a relative vs absolute situation

Can you rationalize the administration of Epi prior to salbutamol in severe asthma exacerbation Pt? I know they both have bronchodilatory properties, just curious as to the additional benefits

Pt with Hx of URTI and a Dx of Asthma. With all signs of croup (Barking cough, low grade fever, severe respiratory distress) on auscultation you hear stridor and whizzing in lungs. Which treatment should be prioritized? Salbutamol vs Epi (NEB)? Thank you

When dealing with an anaphylactic patient, the PCP medical directive says to administer up to 2 doses of epi at a maximum single dose of 0.5mg, whereas the bronchoconstriction AND cardiac arrest medical directives are only one dose at a maximum single dose of 0.5mg. Can some explain why?

Question in regards to the IM epi in ‘less than 50 year old patients with Severe Respiratory distress, bronchoconstriction, and a history of asthma without other contributing cardiorespiratory comorbidities’ Does this mean if the patients is less than 50 year old with Severe SOB and signs of bronchoconstriction and a history of asthma but also has a history of COPD or CHF, then we do not consider IM EPI?

I have two questions with regards to the Bronchoconstriction Medical Directive, under the current (February 22nd, 2021) Considerations for Paramedics Managing Patients during the COVID-19 Pandemic. 1) Are we still only administering IM epinephrine to patients who require BVM ventilations? 2) Are we only administering IM epinephrine under this medical directive to patients presenting with a cough? It was previously stated in the January 4th, 2021 update that: “Paramedics should consider administering IM epinephrine for severe respiratory distress with cough in known asthma patients…” I understand that the top of the new memo states: ” This memo replaces both the May 6th, 2020 and the January 4th, 2021 considerations documents and memos.” Just looking for some clarification on the current practice please. Thank you.

With the new bronchoconstriction update, saying you cant give Epi to pts unless theyre <50, does this apply only to the covid guidelines where you can administer it up to 2x if conditions met (asthma, cough, severe respiratory distress) or does the age now apply to the normal bronchoconstriction directive for Epi where you can give up to 0.5mg once too?

Why was an age restriction of 50 years of age placed on utilizing IM epinephrine for the Bronchoconstrictive Medical Directive in the latest update to the COVID-19 Management considerations?

Is external manual compression of the chest and appropriate prehospital consideration for peri-arrested or arrested asthma exacerbated patients who are showing obvious signs of chest hyperinflation and air trapping. I have read about its anecdotal use on website like EMDocs.net and in the Prehospital Care Journal (Harrison, R. Chest compression first aid for respiratory arrest due to acute asphyxic asthma. Emerg Med J 2010;27:59€“61. doi:10.1136/emj.2007.056119) as a few sources. I have also seen it performed in the emergency department by emergency physicians. I assume with good technique, it can assist with expiration and minimize the risk of barotrauma in these patients who require ventilation. Thank you!

Question: Was just reviewing the SWORBHP document that came out yesterday, just hoping for a little clarification RE bronchoconstriction. In the document it states that we should consider IM administration of Epinephrine for severe respiratory distress w/ cough, hx. asthma. It also states that we should consider using MDI salbutamol only for severe respiratory distress without a cough… My understanding of it would be that we want to keep a surgical mask on the pt. to minimize risk of droplet transmission via cough which you cant do while administering medication via MDI. I understand that if the pt. Has a cough we should use epinephrine as our first line medication same as we normally would if the pt. Is apneic but Are we to be considering these two separate cases for use of these medications and not giving them concurrently during this pandemic? Just wondering as I did not see it specify whether or not we should considering withholding ventolin if there is a cough.

Question: Who can receive IM epi under the new COVID-19 considerations?

Seeking clarification for salbutamol administration down ETT based on the Ask MAC posted April 3rd regarding ETT administration: Are we still able to use our MDI-adapter wherein the MDI canister is inserted and left in, creating a closed-system circuit?

With regards to considerations for Bronchoconstriction it says that with severe resp distress and a cough (with or without need for BVM) that we can consider IM epi as per the bronchoconstriction medical directive. Does that mean they still need to have a hx of asthma?

Does wheezing have to be present in the patient assessment to administer Ventolin?

Question: Case – Adult patient experiencing an asthma attack. Wheezing in all fields (air entry in all fields) and tachypnea. Historically, we’ve been taught to administer Epi in cases of ‘silent chest’, absent air entry in any fields or patient requiring BVM ventilation. The BVM ventilation has always been associated with diminished air entry/silent chest, but not really with hyperventilation. The old BLS stated to assist with BVM ventilation in any patient with a RR>28. Does this mean that if the patient has RR>28, therefore requiring BVM ventilation, he/she SHOULD receive Epi even if there is air entry (albeit wheezing) in all fields?

Question: In the Bronchoconstriction Medical Directive, would a patient ever receive salbutamol followed by epinephrine? Is epi there in case that the patient does not respond to salbutamol and instead gets worse after salbutamol administration? If the patient does not require epi at first, but instead is given salbutamol, then gets worse requiring epi, could that epi administration follow with salbutamol again?

Question: I have a question about the benefits between using MDI vs. nebulized ventolin. I understand the direction is to use MDI as the preferred route. It certainly makes sense with anybody who is infectious but seems counterintuitive when you could be administering drug with oxygen at the same time as with the case of nebulization. There is also a perceived psychological benefit when patients can feel and see the mist. I have heard about studies that were done at Sick Kids to support MDI use. I was unable to locate them. Is there any other evidence you can suggest as to why MDI is the preferred route? Thank you so much for your time.

Question: Some years ago during a recert in the fall a question was posed regarding administering a nebulized treatment of ventolin to a patient who otherwise would not tolerate an MDI but also had a fever above 38C (all other conditions met). The question was answered by stating if all attempts fail for use of the MDI, a nebulized treatment could be administered if all droplet precautions were taken (N95 worn, gown worn closed window to cab area, goes without saying truck disinfected). Is this in fact the case? (Updated)

Question: Would it be a waste of a paramedics time to deliver Salbutamol through a BVM to an unconscious patient while setting up for Epi in the case of an Asthma or anaphylaxis? Would the OPA if used, not block the mist and prevent inhalation? To me, Epi administration (scenario dependent) would be the priority. Thanks

For pediatric VSAs, at what heart rate do we initiate compressions?

Question: In regards to the bronchoconstriction protocol, in order to administer to Epi, the patient must require BVM ventilation and have a history of asthma. What if the patient is alone or they are so short of breath that a history of asthma cannot be obtained? Or possibly this could be their very first asthma attack without an actual diagnosis yet?

We were dispatched to an 8 year old with asthma experiencing SOB; on arrival no wheezing present, lungs clear, no obvious respiratory distress noted, sats at 95 RA; 100 on o2. Mom states he takes puffers but his doctor never actually told her that he has asthma. I found this odd since he is on ventolin and steroid rescue inhaler. If that scenario was different, and we did have to bag him, we absolutely can’t give this patient Epi due to the fact that the doctor never confirmed he has asthma even though he is prescribed inhalers? Is this correct?

Would a BHP patch be appropriate for an order, knowing that his air entry is diminished and the probable cause is severe bronchoconstriction, most likely due to asthma but not confirmed by diagnosis according to parent?

Question: I have heard from our base hospital that MAC is considering removing KING-LT airways from the directives? Is this true, and if so, what supraglottic rescue airway option are they looking at going to, both for ACP’s and PCP’s. Not every patient can be ventilated using BVM alone.

I’ve also heard that they are looking at removing needle cric and intubation from ACP scope? If this is true, then why? Intubation does have major problems in the pre-hospital setting, but outside of cardiac arrest it is a very valuable method of controlling the airway (the gold standard) especially for long transport times or complex patient presentations.

Finally, I understand the theoretical rational behind not using CPAP in asthma PTS, but there are services in North America using it for end-stage asthma exacerbation as a option before intubating the patient. They combine low levels of CPAP (3-5 cmH2O) with a salbutamol nebulizer tied in line to the CPAP mask and are getting good results.

Is there any possibility of a clinical trial of CPAP in asthma exacerbation refractory to salbutamol/epi alone? Is there evidence against using it in asthma (besides theoretical problems).

Question: Could you clarify the Bronchoconstriction directive (epi for asthma exacerbation)? You have to be bagging the patient to give the epi. Our old directives said “any patient with severe SOB from suspected asthma exacerbation AND requires ventilatory support via BVM and OR severe agitation, confusion and cyanosis” but our new directive just says BVM required with history of asthma. I just want to be really clear, now we MUST be bagging them?

Question: In regards to the bronchoconstriction protocol I was recently in a discussion with a coworker disputing the 5-15 min dosing interval. The question was does this interval begin when treatment begins or once a treatment is completed. For example nebulized ventolin may take approximately 5 mins to fully nebulize could I administer a second treatment immediately or would I have to wait 5-15 mins post completion of a treatment. Clarification would be greatly appreciated.

Question: A couple of questions in regards to CPAP use for acute pulmonary edema. I wondered if the medical directive intended for CPAP use in other cases of acute pulmonary edema other than the situation arising from heart failure. For example secondary drowning several hours after initial insult or inhalation injuries in the absence of facial or thorax burns that could be seen with chemicals or fire? It would be reasonable to assume that these insults would cause trauma to the lung tissue and increase the risks for developing pneumothorax as a complication, however in instances like this would CPAP be recommended, beneficial or allowed.

Second part would be the use of CPAP for those with complex medical issues such as those patients with Hx of asthma, COPD and CHF. If you where to treat with CPAP for say evidence of acute pulmonary edema and crackles resolved, but wheezes remained would there be benefit to consider ventolin for bronchoconstriction via MDI or neb through the CPAP device? Typically ventolin is not considered in these instances but auscultation in the prehospital setting has limitations and with complex medical histories cardiac asthma and COPD exacerbation may also be part of the overall medical situation.

I thank you for your comments and insights.

Question: In the area in which I work, there exists a statistical cluster of clients with Myasthenia Gravis. One client that I have now transported at least three times has got the message to call at the first sign of increasing SOB. Most recently he woke up at about 0300 feeling a bit more SOB than normal and not quite right. When we arrived at his house at 0600 he met us outside ambulatory and he had a temp of 39.8C. He was tachypneic. He was in respiratory distress related (In my opinion) to both his MG as well as pneumonia. He adamantly refused the stretcher. He stated that as per his directions he had taken a dose Mestinon when he awoke and that it had not helped. He had a weak or pretty much absent cough. He was placed on placed on high flow O2 by ‘Flow Max’ and was given at least one Ventolin treatment again using the ‘Flow Max’. His condition improved slightly. He was transported with great haste. I have reviewed MG as well as the action of Mestinon. At this point in his disease process he is still requesting that all that can be done be done. Do you have any suggestions as to how we can better care for this client? Putting headers on the ambulance, installing ‘NOS’ or a spoiler is not an acceptable answer. Is CPAP a possibility? I am aware that pneumonia is a relative contraindication for CPAP use. The mechanism of the two disease is quite different but the inability to expand (active muscle use) the chest seems to make them similar. I have attempted to reseach an answer and the best I have gotten after talking with a couple of ED Docs is, ‘Good question. Might buy you some time. How fast can you drive?’ Thank you for your time in considering and answering this question

Question: After 3 treatments of Ventolin be it MDI or NB i was understanding that we could patch for another 3 treatments if needed. I have spoke with other medics and some say yes and some say no could you please verify.

Question: If the patient requires ventolin and has a fever but cannot tolerate the mdi, would it then be appropriate to use the nebulizer.

Question: In the case of a patient who is in obvious respiratory distress with wheezes audible once you make patient contact (i.e. without auscultation), is it necessary to administer o2 via NRB first? Obviously these patients are in need of salbuMtamol and can not tolerate an MDI and spacer. The time it takes to first put on a NRB and then set up a nebulized treatment seems counter productive. Can we start with a nebulized treatment and then apply o2 via NRB after the 1st treatment while we reassess the patient?

Question: Just some clarification in regards to DNR’s. If a patient is having an episode of an exacerbated Asthma and has a valid DNR, do we administer Epi for the asthma? I understand that we cannot “bag” the Patient due to the DNR status.

Question: For a patient with fluid building up in the lungs (recently having the same issue and having to have fluid drained via chest tube) due to a complication of CA, what is the best course of action? It wouldn’t seem that a bronchodilator wouldn’t be effective and since the fluid is of non-cardiogenic nature would nitro work?

Question: Since we’re now able to administer Epi for VSA Anaphylaxis, why are we not able to do so for Severe Asthma VSA?