Pulmonary
Intravenous epinephrine in life-threatening asthma

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Abstract

Study objective: Intravenous epinephrine is a potentially vital therapy for patients with life-threatening asthma but is often avoided because of concerns about its safety. We evaluated the safety of intravenous epinephrine in a series of adults with life-threatening asthma. Methods: We performed an explicit retrospective chart review on a case series of 27 emergency department patients aged 19 to 58 years (mean 25 years) who were treated with intravenous epinephrine for a life-threatening exacerbation of asthma between 1989 and 1997. Explicit criteria for adverse effects, including cardiac arrhythmia or ischemia, hypotension or hypertension, neurologic injury, and death, were defined before chart review. Results: No patient had an arrhythmia other than sinus tachycardia, and there were no cases of cardiac ischemia, hypotension, neurologic deficit, or death. Conclusion: Intravenous epinephrine was safe in this small series of younger adults with acute life-threatening asthma. A prospective trial of its use to better define an efficacy and risk-benefit relationship is justified.

Introduction

Despite gains in the understanding and treatment of asthma, life-threatening asthma is increasing in prevalence, with substantial associated morbidity and mortality.1, 2, 3 Most of the morbidity and mortality of life-threatening asthma is the result of acute respiratory failure and mechanical ventilation,4, 5 and although inhaled selective β-adrenergic agents are generally highly effective, a subset of patients with life-threatening asthma do not respond to such therapy and go on to respiratory failure.2

It is unlikely that epinephrine offers any advantage over inhaled β-adrenergic agents in mild-to-moderate asthma,4, 6, 7 but the possibility that it has a role in life-threatening asthma has never been meaningfully evaluated. Intravenous administration of epinephrine offers a rapid onset of action, reliable delivery of a titratable drug dose, and the option of immediate discontinuation if adverse effects occur.8, 9

We designed this explicit chart review to evaluate the safety of intravenous epinephrine in patients with life-threatening asthma. Explicit aspects of the physiologic response to intravenous epinephrine, side effects, and clinical outcomes temporally associated with its use were investigated.

Section snippets

Materials and methods

We performed this retrospective chart review on a case series of adults treated at either of 2 study hospitals between 1989 and 1997 who received intravenous epinephrine in the emergency department for the treatment of asthma. The institutional review board approved this project.

The care of patients with life-threatening asthma in the 2 EDs, although not driven by any strict protocol, tended to be fairly uniform at the 2 institutions during the period encompassed by the study. This treatment

Results

Over the 8-year study period, 27 patients met the inclusion criteria; all were identified from ICU logs and none from death logs. Fourteen of the patients were women, and the patient's ages ranged between 19 and 58 years (mean 25 years). Eight patients had documentation of intubation for at least one prior episode of life-threatening asthma (Table 1).

All study patients received inhaled β2-agonists, oxygen, intravenous hydration, and intravenous methylprednisolone. In 17 patients, aggressive

Discussion

Although it has been our practice to administer intravenous epinephrine in rare cases of life-threatening asthma that do not respond to aggressive treatment with inhaled β-agents, we were unable to find any studies that attempted to evaluate its safety in this circumstance. We believed that a formal explicit review of our own experience, meeting generally accepted methodologic criteria for the performance of chart review studies,10 would be of significant clinical interest.

Because we embarked

Acknowledgements

We thank Demetrios N. Kyriacou, MD, PhD, for his statistical support.

References (10)

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Address for reprints: David Smith, MD, Department of Emergency Medicine, Scripps Memorial Hospital, 9888 Genesee Avenue, La Jolla, CA 92038-0028; 858-626-6150, fax 858-626-4110; E-mail [email protected] .

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