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Report by: Timothy Nutbeam, ST3 Emergency Medicine
Search checked by: Anna Fergusson, CT1 Anaesthetics
Institution: UHCW Coventry, Coventry, UK
A short-cut review was carried out to establish whether endotracheal adrenaline is useful in acute asthma. Five citations were reviewed, of which one partly answered the three-part question. The clinical bottom line is that there is insufficient evidence to support the routine use of endotracheal adrenaline in patients with respiratory arrest secondary to asthma.
Does [endotracheal epinephrine] lead to a [decrease in mortality] for [patients with asthma in extremis].
A 20-year-old man presents to the emergency department (ED) in extremis. He is known to have asthma. He is treated according to British Thoracic Society guidelines and has a rapid sequence induction, with subsequent intubation. He is difficult to ventilate, due to high airway pressures (pneumothorax has been excluded). You wonder if he would benefit from endotracheal epinephrine?
Medline searched from 1950 to December week 1 2008 using the OVID interface. The Cochrane Library [exp Epinephrine/OR exp Adrenaline] AND [exp Endotracheal] AND [exp Asthma]. Limit to humans AND English language
A total of five papers was found. Only one of these was clinically relevant to the question. However, this was a case report not a study. It reported a significant improvement in cardiorespiratory status with the use of endotracheal adrenaline in a patient with cardiorespiratory arrest secondary to status asthmaticus.
There is no strong evidence for or against the use of endotracheal adrenaline in patients with respiratory arrest secondary to asthma in extremis. Further research is needed, although the nature of the problem and the relatively small numbers involved may make a randomised controlled trial difficult to perform. Local guidelines and clinical acumen should guide treatment.
▸ Leibman JB. Should epinephrine be administered exclusively by the endotracheal route in respiratory arrest secondary to asthma? Am J Emerg Med 1997;15:106–7.
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