Asthma. No financial relationships with a commercial interest to disclose
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1 Asthma in the ED Emily Rose, MD FAAP FAAEM FACEP Assistant Professor of Clinical Emergency Medicine Keck School of Medicine of USC LA County + USC Medical Center No financial relationships with a commercial interest to disclose Know how to treat asthma exacerbations Discuss medication options and dosing Detail an algorithm for what to do when everything you know how to do isn t working Asthma still kills kids MDIs are better tolerated than nebulizers Any kid (or infant) can use an MDI with a spacer Two doses of dexamethasone can be used
2 Improve patient s function Decrease permanent lung remodeling Animal Dander Dust Mites Cockroaches Mold Pollen Smoke URIs Physical Activity Inhaled beta-agonists Inhaled steroids Leukotriene modifiers (zafirlukast, montelukast, zileuton) Theophylline Anti-IgE therapy (omalizumab) Asymptomatic Maintain Activities Peak Flow >80% Best Value
3 Cough, Wheeze, Chest Tightness, Shortness of Breath Wakes at Night Decreased Activities Peak Flow 50-79% Best Value Very Short of Breath Medications not helping Cannot Do Usual Activities Symptoms Worsening Peak Flow <50% of Best
4 250 mcg <20 kg 500 mcg
5
6 Continuous Albuterol Atrovent x3 Steroids Magnesium IVF Parenteral Beta-agonist (epi or terbutalline) Ketamine? Nebulized lidocaine Heliox Methylxanthines Bronchscopy with tpa
7
8 Give most kids beta-2 agonists and steroids with exacerbations Know your options when your meds are working Be vigilant with intubation Boy with inhaler: Sick kid: parentingsquad.com Tripod: airway.jems.com Stressed caricature: myrivendell.wordpress.com Protocol: crashingpatient.com Steroids: nairaland.com Lung diagram: goldenlung.wordpress.com Nebulizer: management-of-disease.blogspot.com Ketamine: emergencymedicineireland.com NPPV: Bipap: Heliox: Vent settings: enotes.tripod.com ECMO: 1.Nebulized lidocaine in mild-moderate asthma. Journal of Allergy and Clinical Immunology. 5// 2004;113(5): Ketamine for management of acute exacerbations of asthma in children. Cochrane database of systematic reviews. 2012;11. 3.Basnet S, Mander G, Andoh J, Klaska H, Verhulst S, Koirala J. Safety, efficacy, and tolerability of early initiation of noninvasive positive pressure ventilation in pediatric patients admitted with status asthmaticus: a pilot study. Pediatr Crit Care Med. Jul 2012;13(4): Brenner B, Corbridge T, Kazzi A. Intubation and mechanical ventilation of the asthmatic patient in respiratory failure. Journal of Allergy and Clinical Immunology. 8// 2009;124(2, Supplement):S19-S28. 5.Camargo Jr CA, Rachelefsky G, Schatz M. Managing asthma exacerbations in the emergency department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations. Journal of Allergy and Clinical Immunology. 8// 2009;124(2, Supplement):S5-S14. 6.Forno E, Fuhlbrigge A, Soto-Quirós ME, et al. Risk Factors and Predictive Clinical Scores for Asthma Exacerbations in Childhood. CHEST Journal. 2010;138(5): Goyal S, Agrawal A. Ketamine in status asthmaticus: A review. Indian J Crit Care Med. Vol : Hunt LW, Frigas E, Butterfield JH, et al. Treatment of asthma with nebulized lidocaine: A randomized, placebo-controlled study. Journal of Allergy and Clinical Immunology. 5// 2004;113(5): Jones BP, Paul A. Management of acute asthma in the pediatric patient: an evidence-based review. Pediatr Emerg Med Pract. May 2013;10(5):1-23; quiz Keeney GE, Gray MP, Morrison AK, et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis. Pediatrics. Mar 2014;133(3): Kelly GS, Simon HK, Sturm JJ. High-flow nasal cannula use in children with respiratory distress in the emergency department: predicting the need for subsequent intubation. Pediatr Emerg Care. Aug 2013;29(8): Masuda Y, Tatsumi H, Goto K, et al. Treatment of life-threatening hypercapnia with isoflurane in an infant with status asthmaticus. J Anesth. Dec Newth CJL, Meert KL, Clark AE, et al. Fatal and Near-Fatal Asthma in Children: The Critical Care Perspective. The Journal of Pediatrics. 8// 2012;161(2): e Nowak R, Corbridge T, Brenner B. Noninvasive ventilation. Journal of Allergy and Clinical Immunology. 8// 2009;124(2, Supplement):S15-S Schivo M, Phan C, Louie S, Harper RW. Critical Asthma Syndrome in the ICU. Clin Rev Allergy Immunol. Nov Szefler SJ, Apter A. Advances in pediatric and adult asthma. Journal of Allergy and Clinical Immunology. 3// 2005;115(3):
9 Thank you!
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