At school: playing football: at home: out of hospital (late Ambulance):

in Syria:

Asphyxial DeathGoblet cell secretion> 150 milli-sec

How may we predict death / life threat ?

Adrenaline IM auto-injectors in all educational establishments

for asthma and anaphylaxis - Good Samaritan clauseNovember 2013

Nothing to lose

Two or three may be needed, through clothes into thigh

0.5 mg adrenaline for everyone

Paramedics will use same dose IM

Demonstration during breaks

Petition 163589

Rule 28: If a Coroner concludes there is a potential for the same cause of death to occur again and that this is preventable, he/she is empowered to draw public attention to this

Jext, Epipen, Emerade in UK. Anapen in EU. Auvi Q in USA, gas powered, speaking - withdrawn

Assessing Severity – Parents, staff

Tesco party blow-outKazoo

Do-Re-Mi-Fa-So-La-Te-DoCan’t speak

Sign 153: British guideline on the management of asthma Sep 2016

9:3:12 In patients with acute severe or life-threatening asthma,

anaesthetists and intensivists should be notified as soon as possible

if there is no improvement in or deterioration of asthma.

Who makes this decision and when?

Pneumothorax?

Treat IV

IV MgSO4 40mg.kg-1 over 4 minutes (5g /10ml ampoule)

then

IV Salbutamol 5mcg.kg-1 bolus, repeated (500mcg /1ml ampoule)

or

15mcg.kg-1 over 10 minutes (Guide)

25kg: 1g Mg; 125mcg salb bolus, or 375mcg 10 min infusion

Allows cough to remove plugs

Smooth muscle relaxation

MgSO4 , beta2-agonists, and inhaled anaesthetics activate adenyl cyclase,

increases cAMP, inhibits calcium entry. Phosphodiesterase inhibitors stop cAMP breakdown

(amino, enoximone, viagra)

Safety of IV MgSO4

Eclampsia

4g bolus, and/or 4 to 6g over 15 minutes

Supra Ventricular Tachycardia (reversion)

2g over 5 seconds (!!) (Wesley 1989)2g over 15 seconds (Viskin 1992)

2g over 60 seconds (Iseri 1985, Hays 1994)

Side effects - Flushing, Warmth, Nausea

Asthma1.2 – 2g over 20 minutes. 3Mg 2012, Shan 2013; little effect

= sub-therapeutic levels. No evidence why 20 min; o’dose?.

Safety of IV MgSO4

Atrial suppressant effects attenuates

or removes the beta1–agonist tachycardia effect

of subsequent IV adrenaline and IV salbutamol

Sellers et al. Br J Anaes 2010 case reports (x7, me) Edwin and Panikkar 2011, Barker and Chin 2103

Not in 2016 guide

Case reports (x7) using sevoflurane during ventilation are.

What stops IV salbutamol use?

Cochrane 2003 15 RCTs ER nebs vs iv beta2s/amino

Swedish 1990: IPPB 5mg x 4, vs iv 350 mcg in 10 min IPPB better, but tachycardia

Salmeron 1994: Neb 5mg x 2 vs iv 500 mcg in 60 min14 hr asthma before trial. Nebs better. No IV loading dose

Browne 1997: Neb 5mg continued; iv NaCl vs 15 mcg.kg in 10 min (children)

IV group 8 hr faster discharge ER

IV 50 kg dose over 10 minsand serum levels

Swedish: 350mcg : 7 ng.ml @ 55 min

Salmeron: 83mcg then infusion : (pre 3.6) 10 ng.ml @ 60 min

Browne: 750mcg : estimate 20-40 ng.ml

Safety of IV salbutamol (terbutaline)

Tachycardia (Mg stops it)

K+ down

Tremor

Lactic acidosis after long-term inhaled and IV(of dubious clinical significance)

IV aminophylline

No benefit in acute asthma, but someone will want to give it

What is used in A&E?

Australia / NZ – Franz Babl: Arch Dis Child 2008

What would you give in a critical asthma scenario?

IV Salb 89%, Mg 55%, Amino 45% (2nd or 3rd )

UK / NI – Morris et al: Thorax 2014. 10 weeks

110 children received IV Salb 61, Mg 67, Amino 52

Commonest order: Salb, Mg, Amino

30 different IV regimes – of dose, rate, duration, and order

Fast resolution of spasm = patient, staff, and savings benefit

World Asthma Guidelines

GuidelinesIV salbutamol IV aminophylline IV magnesium

Child Child Child

Australian 2014 5 mcg.kg-1.min-1 only in ICU 40 mg.kg-1

Over 60 min 10 mg.kg-1 Over 20 min

USA NIH 2007 No proof of efficacy* Not recommended 25-75 mg.kg-1

*sc adrenaline/terbutaline No time for delivery

UK BTS/SIGN 2016

15 mcg.kg-1

over 10 min

Loading dose

5mg.kg-1 over 20 min

After senior consultation

40mg.kg-1 over 20 min (max 2g)

NZ Paediatric 2007. Starship

Hospital

Acute life-threat

15mcg.kg-1

over 1 to 2 minConsider iv in PICU

50mg.kg-1

over 20 min

Give after iv salbutamol

South African

2013

No A&E input

15 mcg.kg-1

Over 10 minFor near fatal in PICU

Severe illness

25-75 mg.kg-1

Over 20 min

Children 2–12 years:Loading dose of 5 mcg/kg/minute (maximum 200 mcg/minute) for 1 hour and then infusion of 1–2 mcg/kg/minute (maximum 80 mcg).

Adults and children older than 12 years:As continuous infusion: initial loading dose of 200 mcg over 1 minute and then start infusion at 5 mcg/minute (can increase to 10 mcg/minute, then up to 20 mcg/minute every 15–30 minutes according to response)As bolus: 250 mcg over 5 minutes.

??

Aus/NZIV salbutamol

Mechanical ventilation rates

USA Krishnan 2006: 2,616 of 65,381 admissions >5yr (4%)(ventilation increased death rate)

Doymaz 2014; early PICU terbutaline reduced mechanical ventilation; late start: 21 of 35 (60%) early: 14 of 85 (16%)

Morris 2014: 10 weeks = 3238 : 7 ventilated (0.2%)

UK PICANet 2015: 200 of 500 admissions (40%)

AUS, Westmead, Sydney: Very rare

IV beta-2 agonist = less respiratory failure?

Wish List

1. Reverse Cochrane conclusions

2. Measure salbutamol /Mg serum levels (athletes)

3. Target “Hot Spots” - Knowsley, Heart of B’ham, Liverpool600+ per 100,000 asthma admission rates

4. A Life threat asthma guide

5. NAP 7

6. Volunteer study IV MgSO 4 before salbutamol

Wish List

Go Dutch?

Enoximone

Oral, IM, IV