Date Published

April 8, 2020

Updated For

ALS PCS Version ALS PCS Version 5.2


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.


Per the latest updates to the Bronchoconstriction Medical Directive (here):

- If COUGH + severe respiratory distress + bronchoconstriction --> NO salbutamol MDI

- If COUGH + severe respiratory distress + Asthma (must have History of  asthma, no COPD or any other cause of respiratory distress) --> IM Epi (up to 2 doses). In this situation, they DO NOT have to be apneic.

You are correct that in order to use the MDI a patient with a cough (and therefore at risk of aerosolizing viral particles) must remove their mask, putting others at risk.  Whereas, with IM epinephrine, they can continue to wear their mask.

Per the COVID-19 Directive #4 for Ambulance Services and Paramedics under the Ambulance Act (here)

-the Chief Medical Officer of Health (CMOH) is of the opinion there is an immediate risk to the health of persons anywhere in Ontario and has issued a directive to any health care provider in Ontario that the following are Required Precautions: Surgical masks are to be used for suspected COVID-19 patients and since there is community spread, any patient with respiratory symptoms should wear a surgical mask.



Keywords are not available for this question at this time.

Additional Resources

No additional resources are available for this SWORBHP Tip.