Are ER Asthma Treatment Protocols changing?

Is it just me or are things changing? Being a frequently flyer in the ER asthma world, Ive noticed more and more changes over the years in the ER treatment protocols for acute asthma flares.

Most notably are the changes in dosage and frequency of administering steroids and certain bronchodilators. When it comes to IV steroids, the standard loading dose still remains at 125mg followed by doses of 40-60mg Q 6 hours, then down to Q8 hours, etc. In most cases now there seems to be an awareness present that giving high dose steroids isnt always a good thing. Greater care is now taken to minimize the negative side effects of the drug by weaning more rapidly if possible. Its not unusual to go from 325mg all the way down to 60mg in just a 3 day period. In the old days I can remember staying on high doses for up to 10-14 days. The side effects and rebounding were a huge problem.

A similar situation holds true regarding Continuous Albuterol nebs. In the past it was common practice (and considered cost effective) to leave a patient on an albuterol neb continuously for up to several days at a time until they opened up. The side effects of tachycardia and hypokalemia were considered worth the risk. Its much more common practice now to limit continuous nebs to only 4 hours per day. The believe being that once the beta receptors become fully saturated with medication, no further bronchodilation will occur. Limiting the dosage to 40mg over a 4 hour period also reduces most of the unwanted cardiac side effects.

Once regarded as experimental in only the sickest of asthmatics, Mag sulfate is gaining popularity and is pretty much given in 2mg doses to anyone who doesn’t respond the first couple of neb treatments.

Can’t say much about Heliox therapy. It’s never really helped me, but Ive seen it help others, especially those with super tight airways.

Then there’s good old Ketamine. Seems to be more of a regional thing and iffy at best, but I can certainly vouch for it’s bronchodilator properties. They put me on it one time while I was at UMPC to avoid intubation and it worked almost instantly, though the hallucinations it can cause were making me really paranoid.

Non invasive ventilation or Bipap therapy is now considered more of a first line defense then it used to be. Youde see it used a lot in sleep apneas, CHF and COPD, but rarely in asthma. Nowadays, if initial ABGs are crappy or the the patient looks tired, an asthmatic patient is usually started on Bipap right away rather than waiting.

Not a lot has changed on the issue of Intubation. It’s still a tough and risky call to determine when it’s appropriate to intubate an asthmatic. Though I think that more emphasis is now placed on how the patient looks in general and their risk for resp arrest, rather than solely based on their ABG results alone. Having said that, I can’t tell you how many times Ive heard them say “your ABGs look pretty good” only to end up being intubated a couple hours later anyway. (Just a reminder to RT’s, that a PCO2 of 45 in a non-CO2 retaining patient is not considered a normal ABG when the patients resp rate is 40. Some of these patients will eventually poop out if some kind of assistive ventilation isnt started.)

Of course all these revelations probably depends on how big and busy the particular ER is and the type of patients who typically show up there. But in general with better triage systems in place ( ie better recognition of asthma symptoms and a better educated staff), there seems to be a more toned down and quieter approach to the treatment of acute severe asthma flares. Unless the patient is obviously crashing or coding, there seems to be less pandemonium in the room. Most people seem to be on the same page, there seems to be less of a reliance to sweat the small stuff, like peak flow readings and O2 sats. More is going into treating first and asking questions later. At least that’s been my experience and I think it’s a positive one. I dont know the official numbers , but all this seems to be saving more lives which is always a good thing.

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