1. 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

2. Asthma Primary Components – Smooth Muscle Spasm – Edema of the Airway – Mucus Plugging of Airway

3. Needed to Treat Asthma 1.Steroids 2.Spacer for MDI 3.  2 agonist 4.1 & 3 5.All of the above

4. 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

5. 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

6. 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. Int J Emerg Med.Nik Hisamuddin NARashidi AChew KSKamaruddin JIdzwan ZTeo AH

7. Oxygen Good in Asthma Unlike Adults w/COPD will NOT depress respiratory drive May need oxygen even when child otherwise clearly improving

8. 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

9. 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

10. 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

11. 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 spacers Take 500 ml plastic cold drink bottles Cut hole in base to fit size and shape of MDI Seal bottle-MDI perimeter w/ glue Use opposite end as mouthpiece

12.  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

13. Statisticians Who WINS? Improvement in FEV1% Steroids in Red—Placebo in Yellow 1.Steroids 2.Placebo Fanta CH: Am J Med 1983;74:845

14. 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

15. Anticholinergics Work best in severe asthma Ipratropium – Nebulize 250 - 500  g every 6 hours Atropine Alternative to Ipratropium bromideAlternative to Ipratropium bromide Dose: 0.03-0.05mg/kg/doseDose: 0.03-0.05mg/kg/dose (max 2.5mg/dose q 6-8 hours)(max 2.5mg/dose q 6-8 hours) Atropine comes in many differentAtropine comes in many different strengths so  yours

16. 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.

17. 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.

18. 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