Download Pediatric Asthma Emergencies

9/18/2014
Sam Delaune, MD
Niswonger Children’s Hospital
Emergency Department
September 19, 2014
Objectives
 Initial assessment of severity
 Specific approach to patient based on severity
 Mild
 Moderate
 Severe
 More aggressive adjuncts
 Hospitalization
 Intubation
4:30 pm on a Friday afternoon
 6 yo female
 Known history of asthma
 URI symptoms and fever for 48 hours
 Wheezing at home
 Albuterol via neb machine every 3 hours
 Still wheezing per mom
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Physical
HR: 128 BP: 128/54 Wt: 27kg O₂ sat: 90% (on room air)  General
 Moderate respiratory distress
 Speaking in brief sentences
 HEENT
 MMM
 TMs retracted bilaterally without effusion
 No conjunctival irritation
 Cardivascular
 Mild tachycardia
 No murmur
 Well perfused, cap refill 2‐3 seconds
 Resp
 Inspiratory / Expiratory wheezing
 No rales or rhonchi
 Suprasternal and intercostal retractions
 GI
 Abdomen soft, non‐tender
 Musculoskeletal/Neuro
 Moving all extremities well
 No focal neuro deficits
Assessment of Severity
 Multiple objective and subjective factors
 Vital signs
 Clinical exam – be sure to take off shirt
 Asthma history – controller meds, albuterol frequency
 Admission history – Floor and PICU
 Regardless, first priority is to improve respiratory status as quickly as possible
Mild
 Intermittent cough
 Exertional dyspnea
 Expiratory wheezing, occasionally intermittent
 Increased use of β agonists, but still with adequate response
 O₂ sat >95%
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Moderate
 Persistent cough
 Normal mental status
 Abbreviated speech
 Dyspnea at rest
 Minimal or transient response to β agonist, using more than q4 hours
 O₂ sat 90‐95%
Severe
 Altered mental status
 Difficulty speaking
 Marked respiratory distress
 Tachycardia
 No / minimal response to β agonists
 O₂ sat <89%
Our patient
 Cough
 Awake and alert
 Speaking, but with difficulty
 Dyspnea
 Some effect from Albuterol, but transient
 Relative hypoxia at 90%
 Moderate
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Basic treatment outline
 Β‐agonist first line
 Albuterol  Either nebulized or through MDI with spacer
 80% of airway dilation occurs in 5 minutes
 Continuous vs. back‐to‐back treatments


Clinical effectiveness
Re‐observation
Basic treatment outline
 Anti‐cholinergic medications
 Atrovent (Ipratropium bromide)


Reduced hospitalization rates
Virtually side effect free
 Corticosteroids
 Oral vs IV/IM
 Dosing
 Prednisone/Prednisolone vs. Dexamethasone
Mild ‐ Treatment
 Aerosolized albuterol
 30 kg and under – 2.5 mg neb
 Over 30 kg – 5 mg neb
 Oral steroids, typically prednisolone
 1‐2 mg/kg, max dose 60 mg
 Typically, mild will not require O₂
 If drop in sat with albuterol, consider chest xray
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Moderate – Treatment
 Aerosolized albuterol
 30 kg and under – 2.5 mg neb x 3, given at 20 minute intervals
 Over 30 kg – 5 mg neb x 3, given at 20 minute intervals
 Ipratropium Bromide
 20 kg and under – 0.25mg x 3, given with albuterol
 Over 20 kg – 0.5 mg x 3, given with albuterol
 Or
Moderate ‐ Treatment
 Continuous hour long nebulized treatment
 5‐10 kg
 10 mg Albuterol + 0.75 mg Ipratropium
 10‐20 kg
 15 mg Albuterol + 0.75 mg Ipratropium
 Over 20 kg
 20 mg Albuterol + 1.5 mg Ipratropium
 And
Moderate ‐ Treatment
 Oral steroids if tolerated
 Prednisolone 1‐2 mg/kg, max 60 mg
 IV/IM Methylprednisolone
 1mg/kg, max 60 mg
 Oxygen as needed
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Severe ‐ Treatment
 Aerosolized albuterol
 Continuous hour long nebulized treatment
 5‐10 kg

10 mg Albuterol + 0.75 mg Ipratropium
 10‐20 kg

15 mg Albuterol + 0.75 mg Ipratropium
 Over 20 kg

20 mg Albuterol + 1.5 mg Ipratropium
Severe ‐ Treatment
 Corticosteroids
 IV/IM Methylprednisolone
 1mg/kg, max 60 mg
 Oxygen as needed
Resistant cases
 Epinephrine IM/Sub Q
 Best in patients with poor inspiratory flow
 1:1000 concentration
 0.01 mg/kg, max 0.4 mg
 Magnesium IV
 25‐40 mg/kg, run over 20 minutes
 Will cause hypotension
 Pair with a bolus
 Terbutaline Sub Q
 0.01 mg/kg, max 0.4 mg
 Heliox
 Primarily an ICU modality
 Mixture of helium and oxygen
 Decreased resistance in airway
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Decision to hospitalize
 Period of observation
 History of prior admissions
 Response to ED management
 Hypoxia
 Distance from hospital
Intubation
 Relatively rare
 RSI if possible
 Ketamine as induction agent
 Potent bronchodilator
 Paralysis only as necessary
ED Discharge plans
 Parental education
 Controller vs Rescue medications
 Continued β agonists
 Every 4 hours
 Home corticosteroids
 Prompt follow up with PCP  24‐48 hours
 Clear reasons to return
 Albuterol > every 4 hours
 Difficulty breathing (retractions, head bobbing, grunting/wheezing)
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Questions?
Disclosure Statement of Financial Interest
 I, Sam Delaune,
DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation
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