PulmonaryIntravenous epinephrine in life-threatening asthma☆
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)
- et al.
Refractory asthma. Part 1: epidemiology, pathophysiology, pharmacologic interventions
Ann Emerg Med
(1997) - et al.
Inhaled salbutomol vs injected epinephrine in the treatment of acute asthma in children
J Pediatrics
(1983) - et al.
Chart review in emergency medicine research. Where are the methods?
Ann Emerg Med
(1996) Asthma—United States, 1982-1992
JAMA
(1995)- et al.
Asthma
N Engl J Med
(1992)
Cited by (26)
Prehospital care for asthma and COPD exacerbations: A review of U.S. state emergency medical services protocols
2022, American Journal of Emergency MedicineEvaluation and Management of Asthma and Chronic Obstructive Pulmonary Disease Exacerbation in the Emergency Department
2022, Emergency Medicine Clinics of North AmericaCitation Excerpt :The IM route is recommended over the SC route, as patients with cardiorespiratory distress or failure have a hyperadrenergic state with reduced skin circulation.15 For patients refractory to IM dosing or those who are profoundly hypotensive, epinephrine should be administered via the IV route in doses of 5 to 20 μg every 2 to 5 min, or via infusion 0.1 to 0.5 mcg/kg/min15,117 Parenteral epinephrine may result in anxiety, nausea, and tremor, but most patients have no adverse events from IV epinephrine. Literature suggests that vital signs, including heart rate, blood pressure, and respiratory rate, normalize in those receiving parenteral epinephrine due to reduced bronchospasm.15,16,117–119
Evaluation and management of the critically ill adult asthmatic in the emergency department setting
2021, American Journal of Emergency MedicineCitation Excerpt :While beneficial in pediatric patients, the data on inhaled magnesium in adult patients are more limited, with a few studies suggesting benefit [145,148]. Parenteral beta agonists via the subcutaneous (SC), intramuscular (IM), or IV route are typically reserved for patients with severe exacerbations who are unresponsive to other therapies or in those who are unable to tolerate inhaled bronchodilators [9,10,16,17,149-161]. Terbutaline is the most common beta agonist administered via the SC route and is given at doses of 0.25 mg [9,10,16,17].
Difficulty Ventilating: A Case Report on Ventilation Considerations of an Intubated Asthmatic Undergoing Air Medical Critical Care Transport
2021, Air Medical JournalCitation Excerpt :The mainstay of treatment includes continuous bronchodilators as well as steroids. Adjunctive therapies include bilevel positive airway pressure, epinephrine, terbutaline, glycopyrrolate, ketamine infusions, as well as inhaled agents such as heliox or anesthetics.11-19 In cases of severe hemodynamic compromise, such as cardiovascular collapse, the use of epinephrine infusions is also used for both vasoactive support as well as bronchodilating effects.11
Anaesthetic management of the child with co-existing pulmonary disease
2012, British Journal of AnaesthesiaCitation Excerpt :I.V. anticholinergic medications should be given and additional steroids (up to 2 mg kg−1 of hydrocortisone or methylprednisolone) might not have immediate effect but can aid in avoiding postoperative bronchospasm. I.V. or subcutaneous β-agonists in the form of terbutaline (10 µg kg−1 over 10 min), epinephrine, or isoproterenol can be used if previous therapy is unsuccessful in terminating the bronchospasm.82–86 I.V. theophylline (5–7 mg kg−1 over 20 min) can be added in refractory situations.18 87
- ☆
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] .