Acute asthma exacerbation

Work-Up

Consider CXR if:

1. Fever
2. Worsening sx (return)
3. Poor response to Rx
4. 1st wheeze

Treatment

(In order of severity)

1. Albuterol
   • continuous = 0.15mg/kg/hr (max 20mg/hr)
2. Atrovent
3. Steroids (solumedrol/prednisone/prednisolone/dex)
   • 2mg/kg (inptn = 1mg/kg Q6hrs; outpt burst = 1mg/kg x4dy)
   • or dexamethasone PO 0.6mg/kg (max 16kg) 1st dose, 2nd dose 36hrs after
4. Magnesium 50mg/kg (max 2gm IV over 20minutes)
5. Epi (1:1000) 0.01mg/kg (max 0.5mg) Q20min x 3 SQ
   • Terbutaline SQ = same as Epi (max 0.25)
   1. • Caution in elderly/CHF
6. Ketamine
7. Non-invasive Ventilation
   1. Consider as alternative to intubation
   2. Alleviates muscle fatigue > larger tidal volumes
   3. Maximize inspiratory support
      1. Inspiratory pressure 8
      2. PEEP 0-3
8. Intubation
   1. Tidal volume 8cc/kg ideal wt
   2. PEEP 0
   3. Assist-control ventilation
   4. Flow rate 80
   5. Resp rate
      1. Start slow to avoid air-trapping
      2. RR ~ 10
      3. Make sure plateau pressure <30
         1. If >30 must lower resp rate
   6. Use bronchodilators even when intubated

Disposition

• Peak Flow = (30 x age-in-yrs) + 30
• Severe = <50% predicted Peak flow
• Severe = <91% SaO2

Source

Rosen's EMcrit Podcast 15