Endobronchial administration of emergency drugs

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Endobronchial emergency drug therapy is reviewed. Although intravenous drug administration is always preferable endobronchial application is a comparatively safe alternative when venous access is not available because an endotracheal tube is usually inserted during CPR. The optimal procedure remains to be clarified, however. Drugs and dosages currently being recommended for endobronchial use are described. With the reservations mentioned above the following recommendations can be made for the endobronchial administration of drugs to adult emergency patients: (1) Endobronchial administration of drugs is indicated in cases of cardiac arrest when an initial examination after the start of mechanical measures suggests that intravenous application will be difficult. This is also the case for emergency patients without cardiac arrest who are already intubated, and for whom the immediate administration of emergency drugs, such as lidocaine or atropine, is urgent and for whom venous injection cannot be carried out or cannot be carried out sufficiently quickly. We cannot at present share the view that the primary endobronchial administration of epinephrine is to be regarded as the treatment of first choice in every case of asystolic cardiac arrest (J. Schüttler et al., Anästh. Intensiwther. Notfallmed., 22 (1987) 63), as in most cases peripheral venous access can readily be established, thus avoiding the possible disadvantages of endobronchial administration (prolonged tachycardia, hypertension, arrhythmia from the depot effect, and also additional impairment of the pulmonary gas exchange). However, the washingin of the administered drug is important after peripheral venous administration. (2) For adults, the present recommendation for the i.v. administration of epinephrine during resuscitation is 0.5–1 mg (7.5–15 μg/kg). Animal experiments show that under stable circulatory conditions ten times as much epinephrine must be administered endobronchially as intravenously in order to produce comparable pharmacodynamic effects or plasma levels. During resuscitation the corresponding value is approximately five times. Nevertheless, because of the dangers from the depot effect, an endobronchial dosage of 2–3 mg should not at present be exceeded. The best method probably consists of a combination of an initial restricted endobronchial dose with, if necessary, a further dose through a venous site which has been established in the interim. This recommendation seems to be reasonable because, as described, there are no exact data on the optimal dosage for epinephrine, even for i.v. administration (3) In the presence of a stable circulation the endobronchial dosage of the other drugs mentioned should also be two to three times that used for intravenous administration. During cardiac arrest not more than twice this dosage should be given, and lidocaine in particular should not be applied at more than 2 mg/kg endobronchially. (4) Saline should serve as diluent giving a total volume of between 5 and 10 ml. (5) In cases of cardiac arrest there are possible advantages in using a deep endobronchial catheter for administration. In this case, as after simple injection into the tube, vigorous insufflations should be carried out immediately after administration. In general we are of the opinion that emergency drugs should still be preferentially administered i.v., in spite of the possibility of endobronchial administration. Endobronchial application should not be used routinely as the method of first choice, as too many questions regarding this technique remain unanswered.