Usability and effectiveness of inhaled methoxyflurane for prehospital analgesia - a prospective, observational study

Abstract

Background Pain relief in the prehospital setting is often insufficient, as the administration of potent intravenous analgesic drugs is mostly reserved to physicians. In Australia, inhaled methoxyflurane has been in routine use by paramedics for decades, but experience in Central European countries is lacking. Thus, we aimed to assess whether user friendliness and effectiveness of inhaled methoxyflurane as sole analgesic match the specific capabilities of local ground and air-based EMS systems in Austria. Methods Observational study in adult trauma patients (e.g. dislocations, fracture or low back pain following minor trauma) with moderate to severe pain (numeric rating scale [NRS] ≥4). Included patients received a Penthrop® inhaler containing 3 mL of methoxyflurane (maximum use 30 min). When pain relief was considered insufficient (NRS reduction < 3 after 10 min), intravenous analgesics were administered by an emergency physician. The primary endpoint was effectiveness of methoxyflurane as sole analgesic for transport of patients. Secondary endpoints were user friendliness (EMS personell), time to pain relief, vital parameters, side effects, and satisfaction of patients. Results Median numeric pain rating was 8.0 (7.0–8.0) in 109 patients. Sufficient analgesia (reduction of NRS ≥3) was achieved by inhaled methoxyflurane alone in 67 patients (61%). The analgesic effect was progressively better with increasing age. Side effects were frequent (n = 58, 53%) but mild. User satisfaction was scored as very good when pain relief was sufficient, but fair in patients without benefit. Technical problems were observed in 16 cases (14.7%), mainly related to filling of the inhaler. In every fifth use, the fruity smell of methoxyflurane was experienced as unpleasant. No negative effects on vital signs were observed. Conclusion In prehospital use, inhaled methoxyflurane as sole analgesic is effective for transport of trauma patients (62%) with moderate to severe pain. Older patients benefit especially from inhaled methoxyflurane. Side effects are mild and vital parameters unaffected. Thus, inhaled methoxyflurane could be a valuable device for non-physician EMS personnel rescue services also in the central Europe region.

Pain Management with Inhalation of Methoxyflurane Administrated by Non-Medical Ski Patrol: A Quality Assessment Study

“…The pain reduction from median NRS 8 to median NRS 5 also corresponds to other European studies where methoxyflurane is used for prehospital pain management, and with similar median initial NRS [ 18 , 19 ]. These studies were performed by trained ambulance workers in Austria and Sweden, respectively.…”

“…The self-titration by the patient was especially useful for missions in difficult terrain and during transport in a rescue bag. This quick approach is also of value to other prehospital providers [ 18 , 21 ].…”

Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update

“…98,204,205 The rapid onset of action and limited side effect profile make methoxyflurane useful as a temporizing measure until other modalities can be established or as a definitive short-term analgesic. 192,206 Recommendation: We recommend methoxyflurane as safe and effective to treat pain in subanesthetic doses in austere environments (strong recommendation, moderatequality evidence).…”

“…98,204,205 The rapid onset of action and limited side effect profile make methoxyflurane useful as a temporizing measure until other modalities can be established or as a definitive short-term analgesic. 192,206…”

Patient-reported side effects and satisfaction of pre-hospital analgesia with low-dose esketamine: a cross-sectional study

“…The most common analgesics in German (prehospital) emergency medicine are fentanyl, morphine, and (es-)ketamine, as well as sufentanil and metamizole [ 6 , 7 ]. Piritramide and inhaled analgesics, on the other hand, are recently gaining ground in emergency medical service [ 8 , 9 ].…”