Asthma

Oxygen to maintain sats >90% (>95% pregnant and peds)
Albuterol (racemic R and S isomers beta-2 agonist) with dosages that vary by institution
            -No evidence that higher dosages produce better outcomes
            -Usual dose is 2.5mg to 5mg neb q20min x 3 prn
            -For severe asthma may use 5mg neb q20 min x 3 or a 1 hr 15mg continuous neb
                        -No incremental benefit of giving more than 15mg Albuterol for acute asthma.
                        -Should make admission or discharge decision after this first hour’s treatment.
            -May also use MDI W/SPACER 6-12 puffs q 20min to deliver 90mcg/puff
                        -Cheap and just as effective as nebs, may do in waiting room or at home
Levalbuetrol (Xopenex, R-isomer) available in 0.63mg and 1.25mg neb solutions
            -Some trials indicate better for chronic asthma, but expensive, so use sparingly
            -Less tachycardia than racemic albuterol (of questionable significance)
Atrovent (ipratropium bromide, anticholinergic) 0.5mg nebs x 3 mixed w/albuterol nebs
            -Albuterol combined with atrovent better than either alone
            -Affects large, central airways
Epinephrine 0.2 to 0.5cc 1:1000 SQ q20-30 min
            -Severe side effects, almost never used as have terbutaline (causes MI if acidotic)
Terbutaline 0.25mg SQ q 20min x 3 prn if pt can’t inhale neb treatments
            -IV dose is 10mcg/kg load then 4mcg/kg/min infusion (for severe exacerbation)
Corticosteroids induce great debate over who gets them, when, what route
            -New literature weekly
            -Give to mod/severe exacerbation
-Clinically: incomplete response to one neb or PEFR<70% pred after ED tx
            -Give to pts on inhaled/oral corticosteroids, recent exacerbation or prolonged sx’s
                        -Works late on inflammation, but also may have an early (1-2 hrs) effect
            -Solu-medrol 125mg IV no better than Prednisone 60mg PO
-IV corticosteroids confer no greater benefit than PO
                        -ONLY give IV if pt very ill and can’t tolerate PO
                        -Increased blood sugars in diabetics (check sugars more freq at home)
            -Discharge with Prednisone 40-60mg qd for 3-10 days (burst, no taper needed)
-Often ordered incorrectly:  Solu-medrol is IM/IV.  Prednisone is PO tablets. Prednisilone (Orapred, Pediapred, Prelone) is PO syrup for pediatric dosing (give 2mg/kg max of 60mg PO in ED and discharge on 1mg/kg for 5 days)
-Inhaled corticosteroids now recommended at ED discharge (especially >2 days asthma per week or >2 nights/month –this is highlighted in red in IBEX as a reminder)

1. Asmanex (mometasone) 220mcg bid or 440mcg qd one single puff daily (mnemonic A-smanex = A single puff daily)
2. If on oral steroids start 440mcg bid
3. Make sure pt gets asthma education and IHCS education by PharmD or RT
4. For <12 yo, use Flovent (Asmanex not yet approved for peds).  88-220 mcg twice daily
5. Budenoside (pulmicort) is only inhaled steroid in nebulized form

Magnesium 1-2gm IV over 30min for severe exacerbations
            -Never been proven efficacious, but probably can’t hurt pt about to be intubated
Theophylline hardly ever given in ED, but check a level on any pt who takes this at home
Heliox may also be used as last resort before intubation
Ketamine (1-2mg/kg IV) may be used for intubation