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. 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 , 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, 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 Signs and Symptoms 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)

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)

25

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 AnginaMedical 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

51 Treatment (cont.) Administer albuterol sulfate (one unit dose) via nebulizer (6 lpm) Begin transport –Do not delay transport to administer medication If symptoms persist, give 2nd dose Upon transfer of patient, reassess and document as before.

52 Treatment (cont.) Medical control MUST be contacted for any patient who refuses medical assistance or transport. Request ALS if the patient is in respiratory failure

53 Documentation ACR : All pertinent data should be recorded in the “Comments” and “Treatment / Response” sections PCR : All pertinent data should be recorded in the “Subjective & Objective Physical Assessment” sections as well as the “Comments & Treatment Given” sections

54 Administrative Restocking of equipment Restocking of albuterol –Paramedics have been instructed not to re - supply BLS units. Follow local procedure.