Bronchospasm (due to Asthma and Obstructive Lung Disease)

Table of Contents

(Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based Guideline Model Process)

Aliases

Asthma, respiratory distress, wheezing, respiratory failure, bronchospasm, obstructive lung disease, albuterol, levalbuterol, duoneb, nebulizer, inhaler

Patient Care Goals

  1. Alleviate respiratory distress due to bronchospasm
  2. Promptly identify and intervene for patients who require escalation of therapy
  3. Deliver appropriate therapy by differentiating other causes of respiratory distress

Patient Presentation

Inclusion Criteria

  1. Respiratory distress with wheezing or decreased air entry in patients 2 yo or older, presumed to be due to bronchospasm from reactive airway disease, asthma, or obstructive lung disease – These patients may have a history of recurrent wheezing that improves with beta-agonist inhalers/nebulizers such as albuterol or levalbuterol
    1. Symptoms/signs may include:
      1. Wheezing – will have expiratory wheezing unless they are unable to move adequate air to generate wheezes
      2. May have signs of respiratory infection (e.g. fever, nasal congestion, cough, sore throat)
      3. May have acute onset after inhaling irritant
    2. This includes:
      1. Asthma exacerbation
      2. Chronic obstructive pulmonary disease (COPD) exacerbation
      3. Wheezing from suspected pulmonary infection (e.g. pneumonia, acute bronchitis)

Exclusion Criteria        

  1. Respiratory distress due to a presumed underlying cause that includes one of the following:
    1. Anaphylaxis
    2. Bronchiolitis (wheezing less than 2 yo)
    3. Croup
    4. Epiglottitis
    5. Foreign body aspiration
    6. Submersion/drowning
    7. Congestive heart failure
    8. Trauma

Patient Management

Assessment

  1. History
    1. Onset of symptoms
    2. Concurrent symptoms (fever, cough, rhinorrhea, tongue/lip swelling, rash, labored breathing, foreign body aspiration)
    3. Usual triggers of symptoms (cigarette smoke, change in weather, upper respiratory infections)
    4. Sick contacts
    5. Treatments given
    6. Previously intubated
    7. Number of emergency department visits in the past year
    8. Number of admissions in the past year
    9. Number of ICU admissions
    10. Family history of asthma, eczema, or allergies
  2. Exam
    1. Full set of vital signs (T, BP, RR, P, O2 sat) – waveform capnography is a useful adjunct and will show a “sharkfin” waveform in the setting of obstructive physiology
    2. Air entry (normal vs. diminished, prolonged expiratory phase)
    3. Breath sounds (wheezes, crackles, rales, rhonchi, diminished, clear)
    4. Signs of distress (grunting, nasal flaring, retracting, stridor)
    5. Inability to speak full sentences (sign of shortness of breath)
    6. Color (pallor, cyanosis, normal)
    7. Mental status (alert, tired, lethargic, unresponsive)
    8. Signs of distress include:
      1. Apprehension, anxiety, combativeness
      2. Hypoxia ( 90% oxygen saturation)
      3. Intercostal/subcostal/supraclavicular retractions
      4. Nasal flaring
      5. Cyanosis

Treatment and Interventions

  1. Monitoring
    1. Pulse oximetry and end-tidal CO2 (ETCO2) should be routinely used as an adjunct to other forms of respiratory monitoring
    2. Check an EKG only if there are no signs of clinical improvement after treating respiratory distress
  2. Airway
    1. Give supplemental oxygen. Escalate from a nasal cannula to a non-rebreather mask as needed, in order to maintain normal oxygenation
    2. Suction the nose and/or mouth (via bulb, Yankauer, suction catheter) if excessive secretions are present
  3. Inhaled Medications
    1. Albuterol 5 mg nebulized (or 6 puffs metered dose inhaler) should be administered to all patients in respiratory distress with signs of bronchospasm (e.g. known asthmatics, quiet wheezers) either by BLS or ALS providers – this medication should be repeated at this dose with unlimited frequency for ongoing distress
    2. Ipratropium 0.5 mg nebulized should be given up to 3 doses, in conjunction with albuterol
      1. Avoid this medication in patients with Cystic Fibrosis due to thickening of respiratory secretions.
  4. Utility of IV Placement and Fluids – IVs should be placed when there are clinical concerns of dehydration in order to administer fluids, or when administering IV medications
  5. Steroids – dexamethasone (0.6 mg/kg, maximum dose of 10 mg) PO/IM/IV should be administered in the prehospital setting for all patients with bronchospasm regardless of severity.
  6. Magnesium sulfate (25 mg/kg IV, maximum dose of 2 g) IVPB over 20 minutes should be administered for severe bronchoconstriction and concern for impending respiratory failure
  7. Epinephrine (1 mg/mL) IM (0.15 mg for 1-25 kg and 0.3 mg for greater than 25 kg) should only be administered for impending respiratory failure as adjunctive therapy when there are no clinical signs of improvement
  8. Improvement of oxygenation and/or respiratory distress with non-invasive airway adjuncts
    1. Non-invasive positive pressure ventilation via continuous positive airway pressure (CPAP). Max of 5 cm H2O
    2. Bag-valve-mask ventilation should be utilized in children with respiratory failure
  9. Extraglottic devices and intubation – should be utilized only if bag-valve-mask ventilation fails – the airway should be managed in the least invasive way possible
    1. Ketamine is preferred for sedative-assisted advanced airway placement

Notes – Bronchospasm (due to Asthma and Obstructive Lung Disease)