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What is Asthma?
1. Airway obstruction Bronchoconstriction Inflammation
2. Reversible Improves in response
to bronchodilators
3. Recurrent Triggers: Infection,
stress, allergens, exercise, cold, foods, smells, etc
Inhaled beta-agonists: Albuterol
Safe and well-tolerated in kids HR up to 200 commonly seen
Intermittent albuterol (MDI and nebulizer) Peak activity at 30 minutes Dosing: 0.15mg/kg/dose– titrate to effect
Continuous albuterol Starting dose: 0.5mg/kg/hour (or 5-15 mg/hour) May go up as tolerated
Ipratropium bromide (Atrovent)
Anticholinergic Bronchodilation and decreased secretions
No cardiovascular side effects, very cheap RCT’s of albuterol/atrovent vs albuterol alone
Clinical improvement Decreased hospitalization Especially most severe
Dosing: 3 doses initially, q6h after that No evidence for continued benefit after first 3
doses
Steroids
Systemic: short burst (3-5 days) Prevent hospitalization, reduce duration of
symptoms Most effective when given early in exacerbation IV/IM equivalent to PO Options
Solumedrol/prednisone 1-2mg/kg/dose (max 60mg) Dexamethasone 0.6mg/kg/day
Of note: no established role of inhaled steroids in acute exacerbation
CC: 18mo boy with history of RAD with viral illnesses
presents to ER with increased work of breathing
HPI: 1 day viral URI symptoms, tactile fevers, stuffy nose; difficulty breathing overnight, fussy and poor PO intake in the morning, parents brought into ER at 8am on 8/31
Meds: none All: NKDA PMH: as noted, immunizations up to date until 1yo Social History: intact family Family History: mom +allergies/asthma
Case #1: 18mo with RAD
Initial Exam in ER:
T: 37.1, P 170, RR 50-60, O2 sat 85% on RA. Gen: nasal flaring, obvious respiratory distress,
somnolent Lungs: Supra-clavicular, intercostal, subcostal
retractions, scattered expiratory wheezes
Brought to Zone 1, Bed 4 and a Zone 1 ED resident assigned to case
Case #1: 18mo with RAD
8:28am: Neb x1 (albuterol + ipratropium bromide) 8:47am: Neb x2 (albuterol + ipratropium bromide) 9am re-assessment by nurse :
T 37.1, P 178, RR 48, O2 sat 98% RA VBG: 7.18/49/32/-10 and Lactate 2.5
~9am: IV Dexamethasone x1 + IV fluids 20ml/kg NS bolus ~9:30: Neb x3 (albuterol + ipratropium bromide) 10am: repeat labs and CXR
VBG: 7.27/35/70/-10 CBC: 9.9>38.3<234 Chem: 143/4.0/113/12/11/0.22 CXR: no abnormalities
Peds Chief Resident assessment at ~10am: Reactive to exam but not crying and not verbally interactive, sleepy, obvious respiratory
distress, nasal flaring, retractions with faint wheezing
What was done well and what could be different at this point in time?
Case #1: ED Management
Case#1: Continued
To Recap: ~1 hr 20 min the team gave albuterol/atrovent X3, IV
dexamethasone, IV fluid bolus RR 40-50, HR180s, O2 sat 98% on facemask Gen: looks sleepy, tachypnea with flaring and retractions,
not very verbal Lungs: faint wheezing
What does this child have?Status Asthmaticus
ED team asks peds team if next steps are to give: More IV fluids and IV Mag
Discussion Question: What could be done to optimize management if we think child has status asthmaticus?
Status Asthmaticus
Status Asthmaticus definition: “unresponsive to inhaled bronchodilators”
Next steps if concerned for status asthmaticus: Maximize O2 delivery Move to continuous
bronchodilator Get IV access Consider dose of IV steroids
What if none of these things work???
Evidence: Magnesium
Bronchodilation via SM relaxation Single IV dose:
RCT data in children has established safety and efficacy
Most beneficial in severe asthmaticus Repeated doses: utility unclear
Must be infused over 20 minutes Adverse effects: flushing, nausea, hypotension
Epinephrine
Easily available! Found on code cart, easy to dose
Fastest absorption when IM, in lateral thigh Previously standard of therapy, now less
favorable due to cardiac effects
Evidence: Terbutaline
IV beta-agonist, Less B2-selective than albuterol
Efficacy: no consistent decrease in symptoms or length of stay shown Recent trials: trend toward improvement?
Minor side effects common Can be given SC or IV
Loading dose of 10 mcg/kg SC or IV Infusion of 0.4mcg/kg/min
Recommendations: Systemic Bronchodilators
Magnesium first-line systemic bronchodilator, for pediatric status asthmaticus
Consider terbutaline as second-line agents IM Epinephrine if no others available
In ED Peds Team Ordered:
Continuous Albuterol at 20mg/hr IV solumedrol IV magnesium sulfate 40mg/kg x1 IV bolus of fluids #3 followed by 1x
maintenance Admit to 4E
(after mag, patient began to look better, crying, better air movement, more prominent wheezing)
Back to Case
For ED Management of Severe Asthma
Ensure systemic steroids given <1 hour consider IV route if severe presentation
Duo-nebs x3 with poor response move to continuous nebulized albuterol and can start 5-15mg/hr and titrate up to effect
Get IV access early IV magnesium the most effective systemic
bronchodilator for status asthmaticus
Key Points for Case #1
ID: 11yo M with history of asthma on Qvar with very poor
compliance presents to ED with significant increased work of breathing.
HPI: normal state of health, but recently moved in with father in SF x1 week with cats and cigarette smoke in home; coupled with poor compliance with Qvar (ICS controller). Brought to ER by ambulance. In route received two albuterol nebs by EMS.
Meds: Qvar, singulair, albuterol PRN All: NKDA PMH: multiple admissions for asthma, no intubations,
immunizations UTD Family History: 2 family members with asthma
Case #2: 11yo M with Severe Asthma
Exam (s/p 2 nebs in ambulance)
Vitals: RR 40-50, O2 sats 92% room air Gen: tripod position, significant respiratory distress, 2-3 word
sentences Lungs: retractions prominent, decreased air movement
ED Management: Continuous albuterol 10mg/hr with 100% O2 face mask IM Epi x1 IV solumedrol IV Mag x1 Repeat IM Epi VBG: 7.3/52/-0.8 CXR: no focal infiltrate Admitted to 4E ICU with “status asthmaticus”
Case #2: In ED
Pediatric Team Management:
Continue albuterol 20mg/hr HFNC 20L/min IV solumedrol q6h IVF at maintenance
Case #2: In ICU
Respiratory Therapy Teaching
• Different devices to provide O2 support on 4E vs 6A vs 6M
• Different ways to deliver continuous albuterol • Optimal flow rate when giving albuterol with HFNC
Pediatric Team Management:
Continue albuterol 20mg/hr HFNC 20L/min IV solumedrol q6h IVF at maintenance
Case #2: In ICU
Continuous albuterol neb ran out in early
morning hours for uncertain amount of time Significant respiratory distress resulting in:
Epi #3 IM given IV Mag #2 given Continuous Albuterol 20mg/hr neb with HFNC
Discussion Question: What system issues that
may have lead to this error?
Case #2: In ICU
Hospital Night #2:
Overnight peds team weaned from 20mg/hr continuous albuterol to 15mg/hr
In AM worsening respiratory distress and increased expiratory wheezes
Team elected to increase albuterol back to 20mg/hr
Discussion Question: Was this patient weaned too quickly? What resources or
metrics can we use to guide our weaning management?
Back to Case#2: In ICU