Open Access Open Access  Restricted Access Subscription or Fee Access

Nebulized morphine for analgesia in an emergency setting

Vincent Bounes, MD, Jean Louis Ducassé, MD, Annie Momo Bona, MD, Florent Battefort, MD, Charles-Henri Houze-Cerfon, MD, Dominique Lauque, MD

Abstract


Objective: To evaluate the efficacy and safety of inhaled morphine delivered in patients experiencing severe acute pain in an emergency setting.
Patients and Methods: Patients were eligible for inclusion if they were aged 18 years or older, with a severe acute pain defined by a numerical rating scale (NRS) score of 60/100 or higher. The intervention involved administering a single dose of 0.2 mg/kg morphine nebulized using a Misty-Neb nebulizer system. NRSs were recorded and were repeated at 1, 3, 5, and 10 minute after the end of inhalation (T10). The protocol-defined primary outcome measure was pain relief (defined by an NRS score of 30/100 or lower) at T10. Secondary outcomes included differences between pain scores at baseline and at T10 and incidence of adverse events.
Results: A total of 28 patients were included in this study. No patient experienced pain relief 10 minutes after the end of inhalation, and no adverse effects were recorded. Respective initial and final median NRS scores were 80 (70-90) and 70 (60-80), p < 0.0001. Despite achieving statistical significance, the value of this point estimate is less than the 14 NRS difference that was defined a priori as representing a minimum clinically significant difference in pain severity.
Conclusion: 0.2 mg/kg nebulized morphine is not effective in managing acute pain in an emergency setting. In spite of the potential advantages of the pulmonary route of administration, opioids should be intravenous prescribed at short fixed intervals to control severe acute pain in an emergency setting.

Keywords


morphine, nebulization, acute pain, opioids, emergency medicine

Full Text:

PDF

References


Alliant L, Bourrier P, Brun-Ney D, et al.: Troisième conférence de consensus en médecine d’urgence de la Société francophone d’urgence médicale. Le traitement médicamenteux de la douleur de l’adulte dans un service d’accueil et d’urgence. Réan Urg. 1993; 2: 321-327.

Innes G, Murphy M, Nijssen-Jordan C, et al.: Procedural sedation and analgesia in the emergency department. Canadian consensus guidelines. J Emerg Med. 1998; 17: 145-156.

Adnet F, Alazia M, Ammirati C, et al.: Conférences d’experts. Modalités de la sédation et/ou de l’analgésie en situation extrahospitalière. Ann Fr Anesth Reanim. 2000; 9: 56-62.

Krauss B, Green SM: Sedation and analgesia for procedures in children. N Engl J Med. 2000; 342: 938-945.

Ward KR, Yealy DM: Systemic analgesia and sedation in managing orthopedic emergencies. Emerg Med Clin North Am. 2000; 18: 141-166.

Masters NJ, Bennett MRD, Wedley JR: Nebulised morphine: A new delivery method for pain relief. Practitioner. 1985; 229: 649-653.

Keles¸ SA, Toprak E, Demirel GC, et al.: Preliminary findings for preemptive analgesia with inhaled morphine: Efficacy in septoplasty and septorhinoplasty cases. Otolaryngol Head Neck Surg. 2006; 135: 85-89.

Thipphawong JB, Babul N, Morishige RJ, et al.: Analgesic efficacy of inhaled morphine in patients after bunionectomy surgery. Anesthesiology. 2003; 99: 693-700.

Chrubasik S, Chrubasik J, Friedrich G, et al.: Postoperative treatment by means of a morphine aerosol: A multicenter study. In Chrubasik J, Cousins M, Martin E (eds.): Advances in Pain Therapy II. Heidelberg: Springer-Verlag, 1993: 151-167.

Chrubasik J, Wüst H, Friedrich G, et al.: Absorption and bioavailability of nebulized morphine. Br J Anaesth. 1988; 61: 228-230.

Zebraski SE, Kochenash SM, Rafa RB: Lung opioid receptors: Pharmacology and possible target for nebulized morphine in dyspnea. Life Sci. 2000; 66: 2221-2231.

Fulda GJ, Giberson F, Fagraeus L: A prospective randomized trial of nebulized morphine compared with patient-controlled analgesia morphine in the management of acute thoracic pain. J Trauma. 2005; 59: 383-388.

Dershwitz M, Walsh JL, Morishige RJ, et al.: Pharmacokinetics and pharmacodynamics of inhaled versus intravenous morphine in healthy volunteers. Anesthesiology. 2000; 93: 619-628.

Masood AR, Thomas SHL: Systemic absorption of nebulized morphine compared with oral morphine in healthy subjects. Br J Clin Pharmacol. 1996; 41: 250-252.

Kendrick DB, Strout TD: The minimum clinically significant difference in patient-assigned numeric scores for pain. Am J Emerg Med. 2005; 23: 828-832.

Bounes V, Charpentier S, Houze-Cerfon CH, et al.: Is there an ideal morphine dosing for pre-hospital treatment of severe acute pain: A randomized, double-blind comparison of two doses. Am J Emerg Med. 2008; 26: 148-154.

Silfvast T, Saarnivaara L: Comparison of alfentanil and morphine in the prehospital treatment of patient with acute ischaemic-type chest pain. Eur J Emerg Med. 2001; 8: 275-278.

Birnbaum A, Esses D, Bijur PE, et al.: Randomized doubleblind placebo-controlled trial of two intravenous morphine dosages (0.10 mg/kg and 0.15 mg/kg) in emergency department patients with moderate to severe acute pain. Ann Emerg Med. 2007; 49: 445-453.

Farr SJ, Otulana BA: Pulmonary delivery of opioids as pain therapeutics. Adv Drug Deliv Rev. 2006; 58: 1076-1088.

Mather LE, Woodhouse A, Ward ME, et al.: Pulmonary administration of aerosolised fentanyl: Pharmacokinetic analysis of systemic delivery. Br J Clin Pharmacol. 1998; 46: 37-43.

McCaig LF, Burt CW: National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary: Advance Data from Vital and Health Statistics: No. 358. Hyattsville, MD: National Center for Health Statistics, 2005.




DOI: https://doi.org/10.5055/jom.2009.0003

Refbacks

  • There are currently no refbacks.