Bronchiolitis Cough, URI, often infant Low grade fever Apnea in neonate Crackles Air trapping Appropriate to try bronchodilators but only continue if helps!!!

Bronchiolitis• Cough, URI, often infant• Low grade fever• Apnea in neonate• Crackles• Air trapping• Appropriate to try bronchodilators but only

continue if helps!!!• Antibiotics NOT indicated or helpful!!• New studies considering hypertonic saline

Asthma

• Primary Components– Smooth Muscle Spasm– Edema of the Airway– Mucus Plugging of Airway

Needed to Treat Asthma

1. Steroids2. Spacer for MDI

3. 2 agonist4. 1 & 35. All of the above

Common Finding in Asthma

• Hyperinflation– Air trapping and subsequent hyperinflation caused

by obstruction of small airways w/premature closure

• Hypoxemia– Ventilation perfusion (V/Q) mismatching caused in

part by mucus plugging

Determine level of Distress

• Look for:– Inability to speak in full sentences– Sweating– Change in consciousness– Decreased or absent breath sounds– Oxygen saturation <90% on oxygen– Tripoding and refusal to lie down

Peak Flow ??

• Although not routinely used in outpatient asthma management may be useful in emergency room management of asthma

• Correlations between capnographic waveforms and peak flow meter measurement in emergency department management of asthma—

• Conclusion: Peak flow measurements and capnographic waveform indices can indicate improvements in airway diameter in acute asthmatics in the ED– Int J Emerg Med. 2009 Feb 24;2(2):83-9

Nik Hisamuddin NA, Rashidi A, Chew KS, Kamaruddin J, Idzwan Z, Teo AH.

Oxygen

• Good in Asthma• Unlike Adults w/COPD will NOT depress

respiratory drive• May need oxygen even when child otherwise

clearly improving

Enough Fluid but NOT too MUCH

• IF dehydrated as is common in asthmatics rehydrate to euvolemia then stop

• Extra fluid may wind up in LUNGS and worsen distress

• As with pneumonia pts w/asthma at risk for fluid overload secondary to SIADH

ß-Agonists

• Mainstay of acute asthma treatment• Cause bronchial smooth muscles relaxation by their

effect on ß2-receptors• Epinephrine still useful but has more cardiac side

effects than newer ones• Albuterol, Salbutamol, and Terbutaline are more

selective 2 drugs with fewer cardiac effects

Metered Dose Inhalers (MDI’s)• Similar effect to nebs if pts using MDI

with spacer– 4-8 puffs every 20 minutes for 3 doses

compares favorably w/ nebs 2.5-5mg q 20 minutes in coordinated patients

• If needed in severe asthma (in monitored situations) MDI dosing can be increased to 1 puff q 30-60 seconds DON”T Allow at HOME!!! Only use this frequently in hospital!

Boulet LP Canadian Asthma Consensus Group. CMAJ 1999;161(11suppl):S53-9.Ackerman AD. Continuous nebs…Crit Care Med 1993;21:1422-4

Home-made spacer for bronchodilator therapy in children with acute asthma: randomized trial” Zar et al Lancet

1999;354:979-82• Interpretation

– Conventional spacer and sealed 500 ml plastic bottle produced similar bronchodilation

– Unsealed bottle gave intermediate improvement– Polystyrene cup was least effective as a spacer

• Use of bottle spacers should be incorporated into guidelines for asthma management in developing countries.

Sealed spacersTake 500 ml plastic cold drink bottlesCut hole in base to fit size and shape of MDISeal bottle-MDI perimeter w/ glueUse opposite end as mouthpiece

agonist SQ (subcutaneous)

• Epinephrine SQ may help avoid need for mechanical ventilation in pts w/status asthmaticus and is still useful in place where nebulizers and MDI’s not available– SQ dose is 0.01cc/kg 1/1000 up to a maximum of 0.5cc

every 15-20 minutes x 3-4 doses or Q4hrs prn (max in adults is 0.3cc)

• Terbutaline SQ can be given every 20 minutes X 3 doses (0.01cc/kg of 1mg/cc drug) up to maximum of 0.4cc

•

Statisticians Who WINS? Improvement in FEV1%Steroids in Red—Placebo in Yellow

-20

0

20

40

60

80

100

120

140

-5 0 6 12 18 24

Hours

FE

V1% Steroids

Placebo

1. Steroids2. Placebo

Fanta CH: Am J Med 1983;74:845

Steroids critical and first line

• Asthma is an inflammatory illness!!• Don’t delay--Give early—can be given po or IV

unless unable to take po

Anticholinergics• Work best in severe asthma• Ipratropium

– Nebulize 250 - 500 mg every 6 hours

Atropine •Alternative to Ipratropium bromide •Dose: 0.03-0.05mg/kg/dose • (max 2.5mg/dose q 6-8 hours)

•Atropine comes in many different strengths so yours

Theophylline

• Formerly mainstay in all asthmatics but• Narrow therapeutic window with serious side

effects led to ↓↓ use• However still probably some patients who

do NOT completely clear without its use• AND it is often one of the few choices in

the developing world.

Theophylline another point of view….(some people still like it even in USA )

• Theophylline when added to continuous nebulized albuterol therapy and IV corticosteroids, is as effective as terbutaline in treating critically ill children…More cost effective…theophylline should be considered early in the management of critically ill asthmatic children”– Wheeler et al Pediatr Crit Care Med. 2005 Mar;6(2):142-

7.

Magnesium• Causes bronchodilation by smooth-muscle relaxation

Dosage recommendation: 25 - 75 mg/kg i.v. over 20 minutes

• If responds may use drip of 25 mg/kg/hour and titrate up by about 5mg/kg/hour attempting to maintain magnesium levels of 4-6 mg/dL* or if in the developing world maintaining knee jerks—if knee jerk present should not have toxic magnesium levels) (*check units to determine therapeutic goal if measuring Mg levels)

• May be particularly beneficial in pts who are prone to Mg because of either prolonged heavy use of Beta 2 agonists or ? malnutrition