PAIN MANAGEMENT WITH PENTHROX INHALER IN PREHOSPITAL CARE:LITERATURE REVIEW

Introduction:Traumas that give symptoms of severe pains could lead to stress induced pain if not given an immediate pain relief. Penthroxinhaler an immediate pain reliever, can be given in pre-hospital services by ambulance officers (paramedics or ambulance nurses). Penthroxinhaler is a low-dose Methoxyflurane single-use inhaler, and has been used for more than 40 years in the medical field in managing trauma pain. Aim:The purpose of this study was to explore the original research related to the prospects of trauma pain management with Penthrox Inhaler, the benefits of using Penthrox inhaler in pre-hospital trauma pain management, and to identify the side effects from using Penthrox Inhaler based on researches published in international journals. Method:The method used in this literature review is the PICO method a type of systematic literature review. Problem/patient: Severe pain. Intervention: Penthrox Inhaler, Comparison: none. Outcome: Pain relief, Keyword : Pain relief. Result:The administration of Low Dose Methoxyflurane in cases of trauma pain showed a very significant effect.GivingLow Dose Methoxyflurane was given faster to the patientcompared to other drugs. With the provision of LDM, the pain reduction was with a VAS value, which stated very satisfying by 42.8% and satisfying 67.3%. The side effects of using gas drugs are generally seen, whether it causes neprotoxicity and the level of tolerability by the patient himself.Before giving Methoxyflurane to patients, must ensure that the oxygen saturation level is above 90% and the maximum dosage given must be 6 ml in the span of 2 hours to reduce side effects.Ambulance officers can be safe with an exposure time of 8 hours while administering Penthrox to patients.


ISSN: 2320-5407
Int. J. Adv. Res. 9(01), 941-949 942 Severe pain not addressed immediately can induce stress, increased the concentration of catecholamine, vasoconstriction, impaired tissue perfusion, tissue of oxygen pressure, hyperglycemia, lipolysis, protein catabolism, disrupted in the wound healing process, risk of wound infection, disturbance in the immune system, disruption of sodium and potassium activities in cells, decrease in cytotoxic T lymphocyte and reduced phagocytes activities (Kotfis et al., 2017).
Penthrox inhaler containing Methoxyflurane which serves asa non-narcotic analgesic effect and can easily be given through inhalation, single-use inhalermaygivenimmedeatlyin pre-hospital services by ambulance officers for relief a severe of trauma painand has been of use for more than 40 years in cases of pain management in Australia and New Zealand (Porter et al., 2018).
Since 1915the Authorities in the UK, allowed to use the methoxyflurane in ambulance services in handling cases of moderate to severe pain in cases of trauma or injury (Forrest et al., 2019), and Methoxyflurane is wide used in other mainland of Europe .
Methoxyflurane is a type of fluorinated hydrocarbon anesthetic, first produced by the company Abbott Laboratories under the trade name Penthrane in the early 1960s, Since 1970 the company About Laboratories developed Methoxyflurane in the form of a single-use inhaler package, and it can be used independently by patients for pain relief,especially in cases of minor and obstetric surgery (Porter et al., 2018).
Low-dose methoxyflurane has been approved by the authorities in Canada, for use in cases of severe acute pain associated with trauma an also for carrying out medical procedures in conscious patients (Campbell et al., 2020).
Methoxyfluraneis a nonnarcoticanelgesic drug, common used for relief severe pain due to injury of musculoskeletal trauma (Kenworthy et al., 2018).Penthorx inhaler is easy to use for handling pain cases in the Ambulance Helicopter service and very helpful in the process of handling pain quickly. Patients will get maximal 2 times 3 ml of Methoxyflurane can be done by the patient himself under medical supervision (Marinangeli et al., 2018).
Picture 1shows the Penthrox Inhaler. Penthrox inhaler contains 3 ml Methoxyflurane substances, which is inserted into the cavity of the inhaler tube, and then rotated around before inhaled through the mouth by the patient (Crankshaw, 2015).

Picture 1:-Penthrox Inhaler Unit.
Picture 2describes how the Penthrox Inhaler works, where after the Penthrox drug is put into the suction tube, the air that is sucked in from the outside will push the penthrox substance into the respiratory tract, the respiratory tract then absorbs the Methoxyflurane quickly.

Inclusion Critera
The article inclusion criteria were: (1) Participants were adult cases with pain in trauma at the pre-hospital service, (2) The intervention used was Penthrox inhalation, (3) the results of the study showed the effect of reducing pain in trauma cases.

Exclusion criteria
The articles exclusion criteria are as follows: articles that are less than 5 years, Non-English articles, non-human activity, duplicate articles, non-relevant articles, and articles that don't answer research questions.

Result and Disccusion: -Pain management with Penthrox Inhaler
A common problem in pain management in the emergency department and pre-hospital is the difficulty in injecting patients, especially in intravenous administration or patients who do not want to take oral medications because of nausea and vomiting. Failure to put the infusion in the ambulance can affect the delay in handling trauma pain, as well as the limited authority of ambulance officers to administer pain medication injections, penthrox inhaler is the choice of ambulance officers in handling trauma pain (Dißmann et al., 2018).Penthroxinhaleris an anesthetic drug as a trademark of Methoxyflurane, which has been used for more than 40 years in Australia in the management of traumatic pain, both in the pre-hospital and in the emergency department (Porter et al., 2018). Methoxyflurane is a fluorinated hydrocarbon anesthetic, where Penthtrox inhaler contains 3 ml per unit package or in terms of the low dose drug Methoxyflurane that can be used up to 6 ml in the treatment of trauma pain, when inhaled for 25-30 minutes, can provide analgesic effect (Porter et al., 2018). Penthrox inhaler is an alternative treatment for trauma pain and in minor surgical procedures or other medical procedures for both adults and children to treat pain due to the procedure (Porter et al., 2018).

Benefit of PenthroxInhaler
The administration of Low Dose Methoxyflurane in cases of trauma pain showed a very significant effect, seen from the length of pain relief (mean 38.1 minutes with SD 34.7 minutes) compared to other analgesic drugs (mean 29.9 minutes with a SD 35.5 minute) (Xia et al., 2019).Giving Low Dose Methoxyflurane was given faster to the patient (mean 21.7 minutes with a SD 24.2 minutes) compared to other drugs (mean 39.2 with SD 43 minutes) (Xia et al., 2019).Traumatic pain was measured using the VAS (Visual analogue Scale) model, figure 4 is a form of VAS that is often used in the emergency department to measure the quality of pain levels (Karcioglu et al., 2018). With the provision of LDM, the pain reduction was with a VAS value, which stated very satisfying by 42.8% and satisfying 67.3%, while the VAS level with the administration of morphine injection showed very satisfying by 18.1% and a satisfactory level of 22. 8% (Voza et al., 2020).

Side effect of Penthrox Inhaler
The side effects of using gas drugs are generally seen, whether it causes neprotoxicity and the level of tolerability by the patient himself. Neprotoxicity occurs, depending on how long the drug is given and at what dose. The safe dose for using Pentrox inhaler is 3 ml, and can be repeated for 0.3 hours, the results show that the fluoride level in the serum is 4.7 micro mol/l, while the blood level is between 0.006-0.026 micro mol/l (Porter et al., 2018). The maximum point for safe use of Penthrox inhaler is a maximum of 2 hours (serum level 50 micro mol/l), if given between 2.5 -3 hours will cause sub-clinical symptoms of toxicity, and toxic levels occur when given more than 5 hours (serum level 90 micro mol/l) (Porter et al., 2018).The level of tolerability of drug use can be expressed by patients in the form of side effects. Side effects occurred when 3 ml of Penthrox inhaler was given with oxygen saturation less than 90%, some patients complained of mild headache and mild somnolence. Some patients complain of the smell of rotten fruit (Porter et al., 2018). 18.1% complained of nausea, euphoria, lightheadedness, hallucinations, dry throat, and paresthesia on the lips. Complaints in children after being given Penthrox inhaler, 25.7% experienced drowsiness and 6.7% experienced mild hallucinations (Porter et al., 2018).It can be concluded that giving Methoxyflurane to patients, must ensure the oxygen saturation level is above 90%, the maximum dose is 6 ml, can be given for 2 hours to reduce side effects.

Penthrox Inhaler Exposure Level to the Ambulance Staff
Every use of a drug in the form of gas, can undeniably give negative exposure to the officer who gave it. The results of observations of giving Penthrox inhaler in 8 hours in a room without cold air conditioning showed that methoxyflurane gas exposure was 0.23 PPM while in a closed room, exposure to Methoxyflurane gas showed 1.5 PPM, the median of 0.017 (0.008-0.736) PPM, the maximum exposure limit the Methoxyflurane gas is 15 PPM. It can be concluded that giving Methoxyflurane during working hours,specifically 8 hours a day, is safe for use by ambulance officers in the handling of cases of trauma pain (Frangos et al., 2020).

Conclusion:-
Common problems and difficulties in pain management in the emergency department and pre-hospital can be resolved easily and quickly by administering Penthrox inhalers compared to giving the patient injection, especially during intravenous administration or when the patient does not want to take oral medication. Penthrox inhaler when inhaled for 25-30 minutes, can provide an analgesic effect on traumatic pain, and provide a fast pain management effect and a longer analgesic effect compared to other methods of pain relief.Penthrox inhaler which contains a dose of 3 ml per package, is safe to use and can be administered by ambulance officers. Before administering the use of Penthrox inhaler, the oxygen saturation of the patients must be above 90% to reduce any possible side effects. The maximum dose of Penthrox inhaler for cases of trauma pain is 6 ml given for 2 hours. Penthrox inhaler does not expose the ambulance officers to lethal levels of exposure limit for Methoxyflurane gas when administering for 8 working hours to the patient.

Suggestion:-
It is recommended that the authorities, namely the Ministry of Health and the Food and Drug Supervisory Agency, to conduct a clinical study of the use of Pentrox inhalers for patients of Asian ethnicity, especially Indonesians and give special permission to ambulance officers (paramedics or ambulance nurses) to use Pentrox inhalers in handling trauma pain cases, without a doctor's prescription.