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Three Part Question

Does [endotracheal epinephrine] lead to a [decrease in mortality] for [patients with asthma in extremis].

Clinical Scenario

A 20-year-old man presents to the emergency department 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?

Search Strategy

OvidSP MEDLINE 1950 to January Week 2 2009. [exp Epinephrine/OR adrenaline.mp.] AND [exp Intubation, Intratracheal/OR endotracheal.mp.] AND [exp Asthma]. Limit to humans AND English language 6.

Embase 1980 to Present. [exp adrenaline/OR epinephrine.ti.ab.] AND [exp Endotracheal Intubation/OR exp endotracheal tube/] AND [exp Asthma].
The Cochrane Library Issue 1 2009. [MeSH descriptor Epinephrine explode all trees] AND [MeSH descriptor Intubation, Intratracheal explode all trees].

Search Outcome

A total of 51 unique papers was found. Only one of these was clinically relevant to the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Leibman JB 1997 USA	One patient with status asthmaticus	Case report	Clinical improvement	After endotracheal adrenaline	Case report, only 1 patient, improvement could have been due to other treatment given

Comment(s)

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 would make a randomised controlled trial difficult to perform. Local guidelines and clinical acumen should guide treatment.

Clinical Bottom Line

There is insufficient evidence to support the routine use of endotracheal adrenaline in patients with respiratory arrest secondary to asthma. However, it could be considered in patients unresponsive to conventional treatment.

References

1. Leibman JB Should epinephrine be administered exclusively by the endotracheal rout e in respiratory arrest secondary to asthma? Am J Emerg Med 1997 Jan;15(1):106-7