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).

 Thanks for your question. Is your Base Hospital the Southwest? If so, this is not a message that our Base Hospital supports. While the King LT is not without its challenges, the Ontario Base Hospital Group (OBHG) MAC is not considering removing it from the Advanced Life Support Patient Care Standards. The same is true for needle cricothyrotomy and intubation.

As for your question regarding the management of acute asthma exacerbations, few studies can be found studying the use of CPAP specifically. Most studies have been hospital based and use bi-level positive airway pressure modalities (BIPAP). There is absolutely a need for further evidence in pre-hospital care as to the role of CPAP for severe asthma. As you have astutely pointed out, not every EMS system creates medical directives based upon established medical literature.

Here are some references related to the topic from:

Bauman,K Hyzy, R Noninvasive positive pressure ventilation in acute respiratory failure in adults In: UpToDate, Parsons, P(Ed), UpToDate, Waltham, MA, 2013.

Soroksky A, Stav D, Shpirer I. A pilot prospective, randomized, placebo-controlled trial of bilevel positive airway pressure in acute asthmatic attack. Chest 2003; 123:1018.

Shivaram U, Miro AM, Cash ME, et al. Cardiopulmonary responses to continuous positive airway pressure in acute asthma. J Crit Care 1993; 8:87.

Meduri GU, Cook TR, Turner RE, et al. Noninvasive positive pressure ventilation in status asthmaticus. Chest 1996; 110:767.

Patrick W, Webster K, Ludwig L, et al. Noninvasive positive-pressure ventilation in acute respiratory distress without prior chronic respiratory failure. Am J Respir Crit Care Med 1996; 153:1005.

Fernández MM, Villagrá A, Blanch L, Fernández R. Non-invasive mechanical ventilation in status asthmaticus. Intensive Care Med 2001; 27:486.

Lim WJ, Mohammed Akram R, Carson KV, et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev 2012; 12:CD004360.

Nowak R, Corbridge T, Brenner B. Noninvasive ventilation. J Allergy Clin Immunol 2009; 124:S15.

Airway/Breathing,Bronchoconstriction,Continuous Positive Airway Pressure (CPAP),Supraglottic Airway

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