Asthma and diving

[stimpy4242]

Also I want to add that while the quote talks about anaphylaxis, IM is recommended anytime epi 1:1 is to be given.

 

[ScubaDocER]

Ooh, not keeping up to date on the latest in prehopsital treatment of asthma? Epi 1:1000 shots are being given IM not SQ. Please refer to this:
SpringerLink - Journal Article
In addition, you could refer to these medical protocols:
http://miemss.org/home/LinkClick.aspx?fileticket=PcFzAVnOA4M=&tabid=106&mid=534

In addition racemic epi is given to pediatrics.

In regards to Epinephrine administration for anaphylaxis, it
is now recommended to give epinephrine IM versus SQ.

Studies in children revealed that SQ injection into the deltoid region
took approximately 34 (+ or - 14) minutes to reach peak concentrations
versus 8 (+ or -) minutes when given IM in the lateral thigh.

Buck, Ml. Pediatric Pharmacotherapy. 2008;14 (5)

The IM route for epinephrine is also a component of the recommended
medication intervention in the emergency department of Cincinnati
Children's Hospital Medical Center for managing anaphylaxis.

I encourage you to do your own research as well and come up with your own conclusions. Please read the information and then let me know what you think about IM epi. Please never use the word NEVER...its very closed minded.

I understand your point of view when you say psychological stress, but your previous post said stress hormones, which typically refers to adrenaline among some others.

I really try to stay away from a he said/she said discussion with anyone so I'll avoid that here as well. I'll seek to correct what I perceive to be misstatements and move from there. The standard of care for the treatment of asthma involves nebulized beta agonists. Racemic Epi is such a medication so I agree with you on that point. Actually that was not in dispute. What you do in the prehospital setting is not necessarily what is considered standard of care in the in hospital setting. Perhaps that is where we disagree. I respect that as an EMT (I assume that from the credentials in your post) there are things you may do in the field that differ from what I would do as a physician in the Emergency Department. The use of IM epinephrine is not considered the standard of care in the ED for the treatment of asthma. SQ epinephrine is safer and has fewer systemic side effects than IM or even IV epi. This is also true of a mild or moderate anaphylactic reaction. For patients in shock, then the IV use is preferred. IM epi is not a bad idea for anaphylaxsis, just fraught with additional clinical consequences that most physicians prefer to avoid.

I have no problem using the word never, especially when I feel it is appropriate. I will concede that I should have added the word "should" before it. IM epi should never be used in the treatment of asthma. I cannot speak for other physicians and their practices so I cannot say never as an absolute. There is rarely a need for IM epi in the management of acute asthma when their are better options available, including albuterol, racemic epi, atrovent and steroids (which will not work immediately but will help within 30 minutes or so). The use of IM epi causes many systemic effects that can create problems where none existed, and if accidentally administered IV, can be fatal. My clinical experience has never required me to use IM epi in the treatment of an acute asthma attack, including the 6 month old child I treated today with racemic epi.

Actually stress hormones can mean many different hormones, including glucocorticoids and mineralocorticords. Adrenaline is just one of several hormones that I could have been referring to. There is no typical stress hormone. As I referred to in my previous post, the release of stress (and I'll use epi here) hormones does not improve the clinical situation. It causes a raid heart rate and increased work of breathing which causes muscle fatigue and impending respiratory failure when asthmatics are attempting to ventilate across obstructed airways. The best use for epi or medications with epi like actions in asthmatics is inhaled. Please don't confuse the actions of a drug like epi with the appropriate clinical management of a patient in respiratory distress. While epi is released during times of stress, such as an asthma attack, this does not mean that the epi that is released is helping the patients clinical condition.

I appreciate your request that I do my own research. I am comfortable and confident in my clinical and academic years as a physician to feel at ease with the appropriate management of asthma.

The initial aspect of this thread dealt with asthma and diving. This was the focus of my response as opposed to the prehospital management of asthma. Since I manage the results of prehospital treatment, we can certainly discuss that at another point in time. My hope is that asthmatics and the Instructors for asthmatics can learn more about how asthma affects the body so that if they choose to participate in diving, they do so from an educational perspective. Thank you again for participating in this thread.

 

[ScubaDocER]

Also I want to add that while the quote talks about anaphylaxis, IM is recommended anytime epi 1:1 is to be given.

See above.

 

[Thalassamania]

I don't think that asthma and anaphylaxis are the same thing. Are they?

 

[ScubaDocER]

Don't want to get in the middle but...Sorry ScubaDoc, Thousands of children and adults have been giving themselves:shocked2: IM 1:1000 epi at least a decade Ever seen a patient with one of these bad boys EpiPen | Allergy | Allergic Reactions | Anaphylaxis Allergy

The post was at 3am- I'll give you a pass

Frogman159, Pharm.D

Not a problem frog . I am familiar with the Epipen. It is a great prehospital tool for patients that are in the field and have no other means to administer medication. It is effective and helpful for many patients. My discussion had more to do with inhospital management, where this is rarely done do to the above mentioned consequences. I am a night owl so a lot of my posts are in the AM hours .

 

[stimpy4242]

Sorry, my mistake, I forgot that if someone were to have an asthma attack while diving, it would be while dive in the scrub tub of a local ED. Not in the prehopsital setting. In additon, its not only prehospital providers that use IM epi in cases of SEVERE asthma attacks. In fact it is recommended by the AAOS. It is recommended by AHA. It is also by the AMA. EPI pens as the PharmD pointed out are prescribed to asthmatics as a way to fight a sever asthma attack. I do not disagree with you that steroids, combivent, or terbutaline aren't other ways of dealing with the issue, but so is epi. And it is considered when it is a severe attack. Often right before the laryngoscope blade is brought out.

However, I will once again state, you are right, your treatment is not wrong. It might just not be cutting edge, which I have heard is often met wit resistance...I am based in baltimore and spend my doctoral research at Hopkins...I think something edgey and something that met resistance started there too, something about that crazy voodoo heart surgery stuff...don't forget where your medicine comes from, it comes from previous physicians who made an impact by going beyond the barriers and pushing the limits of medicine. Sure many time with great failures, but a few times, with HUGE success...

Try to be open minded...

 

[stimpy4242]

It is a great prehospital tool for patients that are in the field and have no other means to administer medication.

Its interesting you put it that way, funny, I thought these patients were ALSO prescribed rescue inhalers...albuterol, combivent, same doses even that are given in the hopsital, sure they aren't a continuous nebulized albuterol, but why then are they given an epi pen to "cure" the problem if it gets too severe?

In addition, prehopsital providers can do continous nebulized albuterol and atrovent. I would suggest striking up a conversation with the next paramedic that walks in, or even their medical director to find out why they are doing what they do, I guarantee it didn't come about without a big committee of doctors and others...

 

[ScubaDocER]

I don't think that asthma and anaphylaxis are the same thing. Are they?

They are different but can be related Thal. Asthma is a exaggerated response to a stimulus that usually only affects the lungs. This usually occurs as a result of the release of leukotrienes that cause mucosal inflammation and narrowed airway passages, as well as bronchoconstriction. Anaphylaxsis is a generalized over exaggeration to a stimulus that can effect the entire body typically caused by the release of histamine. This causes swelling of affected tissues through the dilitation of blood vessels. This also results in the characteristic rash, such as occurs with a reaction to mushrooms. A patient with an anaphylactic reaction may develop wheezing or asthma like symptoms. But asthmatics wont necessarily develop anaphylaxsis.

The treatment for both can be similar. Asthmatics typically received inhaled nebulized treatment such as albuterol or atrovent, as well as steroids.

Anaphylactic patients typically receive benadryl and may receive steroids as well. If the swelling occurs in the bronchial tree of the lung, they may also receive albuterol to help keep the airways open until the benadryl can blunt the effects of the excessive histamine release.

 

[ScubaDocER]

Sorry, my mistake, I forgot that if someone were to have an asthma attack while diving, it would be while dive in the scrub tub of a local ED. Not in the prehopsital setting. In additon, its not only prehospital providers that use IM epi in cases of SEVERE asthma attacks. In fact it is recommended by the AAOS. It is recommended by AHA. It is also by the AMA. EPI pens as the PharmD pointed out are prescribed to asthmatics as a way to fight a sever asthma attack. I do not disagree with you that steroids, combivent, or terbutaline aren't other ways of dealing with the issue, but so is epi. And it is considered when it is a severe attack. Often right before the laryngoscope blade is brought out.

However, I will once again state, you are right, your treatment is not wrong. It might just not be cutting edge, which I have heard is often met wit resistance...I am based in baltimore and spend my doctoral research at Hopkins...I think something edgey and something that met resistance started there too, something about that crazy voodoo heart surgery stuff...don't forget where your medicine comes from, it comes from previous physicians who made an impact by going beyond the barriers and pushing the limits of medicine. Sure many time with great failures, but a few times, with HUGE success...

Try to be open minded...

Uh...Thanks for the diatribe. As stated before, this is staring to get off topic. We can discuss the management of asthma in another location.

 

[ScubaDocER]

Its interesting you put it that way, funny, I thought these patients were ALSO prescribed rescue inhalers...albuterol, combivent, same doses even that are given in the hopsital, sure they aren't a continuous nebulized albuterol, but why then are they given an epi pen to "cure" the problem if it gets too severe?

In addition, prehopsital providers can do continous nebulized albuterol and atrovent. I would suggest striking up a conversation with the next paramedic that walks in, or even their medical director to find out why they are doing what they do, I guarantee it didn't come about without a big committee of doctors and others...

See above.