In this episode, I’ll discuss what to use for acute asthma exacerbation if you run out of MDIs and can’t use nebulizers.
Many hospitals are prohibiting nebulizer use during the COVID-19 pandemic to protect staff from disease transmission during this aerosol-generating procedure.
This has led to the increased use of MDIs to treat acute exacerbations of asthma. It is possible that this increased usage would deplete supplies of MDIs and leave clinicians searching for alternative ways to treat a patient with acute exacerbation of asthma.
Asthma guidelines do provide an alternative, although it is typically thought of in the context of prehospital care. If MDI or nebulizer therapy cannot be performed or is unavailable, subcutaneous beta agonists such as epinephrine or terbutaline may be used.
The dose of epinephrine according to the asthma guidelines is:
0.3 to 0.5 mg subcut every 20 minutes x 3 doses
The dose of terbutaline according to the asthma guidelines is:
0.25 mg subcut every 20 minutes x 3 doses
Of the two choices, terbutaline may be preferable due to its longer duration of action.
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Here is what we are doing IF we run out of MDIs:
1. Epi 0.1-0.2mg IM/SQ PRN SOB (MR x 2)
My experience is that the 0.3mg (and especially the 0.5mg) dose is a bit overkill. Pts dont tolerate them as well and lower doses tend to yield favorable results (depending on pt PK characteristics and severity of presentation). Not saying we wouldnt give more for severe SOB but I think lower doses do the trick.
2. Post EPI (if not intubated then) Albuterol 4mg PO TID scheduled thereafter
An ounce of prevention is worth a pound of gold 😉
Another option is to have RT put on full PPE and just congregate the COVID SOB pts in one area of ED then neb those pts in negative pressure room. Have RT go from room to room…
We still have MDI present but the above are two options for our contingency plan. We were not able to get enough Terbutaline to make it part of our plan B plan…. IMO you also want to simplify your ED pan Bs as since they are already outside the norm, dont give several plan B options; more: if this is out, do this (not this or this) if that makes any sense.
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Lastly, another thing to consider is:
Before you run out of MDIs, start the above for younger pts without cardiac hx to preserve MDI. You dont want to be in position where you have used your MDI on younger pts and now only option is EPI for the CABG 70 year who p/w EKG abnormalities and SOB…
Sorry for typo’s trying to multitask…just blame my writing on covid 😉
Awesome points, thank you for sharing Pharmacy Ash!