Asthma Management in NYC: Improving Outcomes

1. Introduction • In 1996, asthma was the leading cause of hospitalizations in New York City for children (up to the age of 14 ). • In 1995, asthma hospitalizations for children of the same age group were 3 times the national average and 5 times the state average.

2. Introduction (cont.) • In New York City, EMTs & Paramedics treat approximately 50,000 asthmatics each year. • While these patients benefit from bronchodilator therapy, the availability of ALS response units cannot always be assured. • As a result, these patients are treated by EMTs.

3. Mortality from asthma is increasing worldwide From 1980 - 1987, the death rate has increased by 31% in the United States. 5,000 deaths per year.

4. Many studies have shown The efficacy and SAFETY of albuterol in the treatment of bronchospasm associated with asthma.

5. An expanded scope of practice for EMTs Could provide benefits to the population of asthmatics in New York City

6. May 1, 1998 - 2 new call types were implemented • ASTHMP - for patients under 15 years old • ASTHMA - for patients 15 years of age or older

7. Inclusion Criteria • Patients between the ages of 1 and 65 years old (with no ALS immediately available). • Patients complaining of difficulty breathing secondary to an exacerbation of their previously diagnosed asthma.

8. Exclusion Criteria • Patients with a history of hypersensitivity to albuterol sulfate. • Patients exhibiting signs of respiratory failure (a patient requiring ventilations).

9. Adult Respiratory Failure • Decreased level of consciousness • Too dyspneic to speak • Cyanosis (despite oxygen therapy) • Diminished breath sounds • Patient requires assisted ventilations

10. Pediatric Respiratory Failure • Ineffective respiratory effort with central cyanosis, agitation or lethargy, severe dyspnea or labored breathing, bobbing or grunting and marked intercostal & parasternal retractions.

11. Differential Diagnosis of Bronchospasm • COPD • Foreign body obstruction • Pulmonary Embolus • Anaphylactic reaction • Pulmonary Edema • Asthma

12. Pathology of Asthma • Reversible smooth muscle spasm of the airway associated with hypersensitivity of the airway to different stimuli. Primarily an inflammatory process. • Smooth muscle contractions • Mucosal edema • Mucous plugging

13. The Lungs

14. The Lower Airway

15. Triggers of Asthma Attacks • Allergies • Infection • Stress • Temperature changes • Seasonal changes

16. Dyspnea Wheezing Tachypnea Tachycardia Cyanosis Cough Accessory muscle use Inability to speak….. in complete… sentences. Anxiety (hypoxia) Prolonged expiratory phase Tripod positioning Nasal Flaring (infants) Signs and Symptoms

17. Respiratory Muscle Fatigue • Muscles are overworked to compensate for problem. • Increased work of breathing • Can lead to exhaustion and respiratory failure.

18. Assessment of The Asthma Patient

19. Assessment of the Asthmatic • Chief complaint • History of present illness • Past medical history

20. History of Present Illness • How long • Events leading up to… • How severe (Borg Scale) • Aggravating / Alleviating factors • Other complaints • Steroid use in last 24 hours (p.o. / inhaled) • Other medications

21. Past Medical History • Confirm asthma history • Other medical conditions (cardiac) • E.D. visits for asthma in the last 12 months • Hospital admissions for asthma in last 12 months • Previously intubated due to asthma? • Allergies to medications, etc.

22. Note: Do not delay treatment to solicit a patient’s medical history(except: asthma,allergies and cardiac history.)

23. Physical Examination • Respiratory distress vs. Respiratory failure • Posturing (tripod positioning) • Pursed lip breathing • Vital signs • Skin color, temperature and moisture • Ability to speak... in complete... sentences • Accessory muscle use

24. Physical Examination (cont.) • Borg Scale (0 - 10) • Peak flow • Height (you may ask patient)

26. Peak Flow Meter

27. Auscultation of Breath Sounds • General requirements for successful evaluation: • Patience • Effective technique • Good hearing • Knowledge of sounds

28. Physical Examination (cont.) • Assessing lung sounds • Rales • Rhonchi • Stridor • Wheezing

29. Lung Sounds Found In Common Emergency Conditions • C.O.P.D. • Diminished • Wheezes • Prolonged expiratory phase • Pneumonia • Rales (usually in one area)

30. Lung Sounds Found In Common Emergency Conditions • Pulmonary Edema • Diminished Sounds • Rales (usually bilateral) • Asthma • Diminished Sounds (may be on one side) • Wheezes • Prolonged expiratory phase

31. Wheezes • High pitched, continuous sounds • Occur on inspiration or expiration • Result of narrowed bronchioles

32. Wheezing Assessment • No Wheezing • Wheezing (audible with stethoscope) • Wheezing (audible without scope) • Poor air exchange (diminished lung sounds)

33. Absent or Diminished Sounds • Pneumothorax • Hemothorax • Obesity • Hypoventilation • Fluid or pus in pleura or lung • COPD or Asthma with poor airflow

34. Stethoscope Placement

35. Technique • Sit patient up • May not be possible to auscultate all areas • Place diaphragm firmly on chest wall • Avoid extraneous noise • Avoid prolonged examination of the chest

36. Technique • Have the patient open mouth and take deep breaths. • Avoid hyperventilation. • Listen at each location and note abnormalities.

37. Albuterol Sulfate Ampules

38. Pharmacology: Albuterol Sulfate • Actions • Bronchodilator • Minimal side effects • Nervousness • Palpitations • Dizziness • Drowsiness • Flushing • Chest discomfort • Tachycardia • Muscle cramps • Dry mouth • Insomnia • Tremors • Weakness

39. Indications for Project Use • Relief of broncospasm due to exacerbation of asthma. • Use with caution for patients with: • Previous M.I. • C.H.F. You must contact • Angina Medical Control • Arrhythmias

40. Contraindications • Patients with known hypersensitivity to the medication or its components. • Patients in respiratory failure (those patients requiring ventilatory assistance)

41. Dosage • One unit dose, 3.0 cc or 0.083% Via nebulizer at 6 liters per minute or at a flow rate that will deliver the medication over 5 to 15 minutes. • Dose may be repeated if the symptoms persist for a total of 2 doses.

42. 5 rights of Medication Administration • Right Patient • Right Drug (beware look alikes) • Right Dosage • Right Route • Right Time

43. Check 3 Times For: • Expiration Date • Discoloration and Clarity • Particulate matter

44. Administration (cont.) • Assemble nebulizer • Add medication • Attach to oxygen regulator • Set flow meter to 6 lpm • Instruct patient on use • inform adult patient • modify delivery for very young patients

45. Nebulizer

46. Assembled Nebulizer

47. Assembled Nebulizer and Oxygen Tubing

48. Treatment of Asthma Patient • Assess breathing • Administer oxygen via non - rebreather or assist ventilations • Monitor Breathing • Do not permit physical activity • Place patient in position of comfort

49. Assess and Document prior to administration of albuterol • Patient is between 1 and 65 years of age • Dyspnea is secondary to previously diagnosed asthma • Vital signs • Ability to speak… in complete... sentences • Accessory muscle use • Wheezing assessment

50. Assess and Document prior to administration of albuterol (cont.) • Borg scale (0 - 10) • Peak flow • Contact medical control if patient has pertinent cardiac history • “The 5 rights” of medication administration