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Asthma 3
Asthma 3
Toni Petrillo-Albarano, MD
Division of Pediatric Critical Care
Children’s Healthcare of Atlanta
Asthma: Increased Severity
Hospitalization Increased 28%
-MMWR, CDC
Asthma: Increased Severity
Death Rate Increased 118% (1980 -
1993)
-MMWR, CDC
The Cost of Asthma
Risk Factors:
Severe disease - history of intubation,
seizures, rapid progress
Lack of adequate support systems
Psychologic disease
Children Who Die from Asthma
Risk Factors:
Lack of perception of severity; self-
weaning
Males
Exclusive reliance on b agonists
50% of deaths prior to hospital
Mechanisms of Status
Asthmaticus
Bronchospasm
Mucous
Hypersecretion Mucosal
edema
Relative hypoxemia:
V/Q mismatch
hypoventilation
Hypoxemia bronchoconstriction
agonists impair hypoxic pulmonary
vasoconstriction shunt
Oxygen to keep pulse ox > 92%
Status Asthmaticus
Beta2 Agonist Therapy
Most studies:
inhaled therapy > to IV agonist
Greater side effects with IV
Potential benefit severe bronchospasm
Experience anecdotal with severe SA
IV Terbutaline:
bolus 10 mcq/kg
infusion 0.1-4.0 mcq/kg/min
Status Asthmaticus
Isoproterenol (Isuprel)
Tachycardia
Dysrhythmias
Peripheral vasodilation
Increased myocardial O2 consumption
Decreased coronary O2 delivery
“Splanchnic steal” by skeletal muscle
Severe Asthma
Intravenous Isoproterenol
Equivocal results
high incidence of dysrhythmias
report of fatal myocardial ischemia
“DO not use IV Isuprel in the treatment
of asthma ...”
-NHLBI
statement
Status Asthmaticus
Subcutaneous Agonists
Epinephrine/Terbutaline
No advantage over inhaled agonists
Increased side effects
Indications:
inability to cooperate with inhalation therapy
rapidly decompensating patient
failure to respond to inhaled beta-agonists
Status Asthmaticus
Anticholinergics
Airway
agonist
Sympathetic
Parasympatheti
Xc
Vagolytics
Status Asthmaticus
Inhaled Ipratropium + Albuterol
*
*
* * *
* *
*
* * *
* *
*
-Schuh, J Peds,
* p < .05
Status Asthmaticus
IV or oral Corticosteroids
Mechanism of Effect:
interferes with leukotriene,
prostaglandins synthesis
prevent cell migration
up-regulate airway receptors
Status Asthmaticus
IV or oral Corticosteroids
Recommended dose
Prednisone or methylprednisolone
suggested initial dose 2 mg/kg
1 mg/kg IV q 6 hours (max 60 mg) x 48
hours,
then 1mg/kg q 12 hours for 3-5 days
-NHLBI Expert
Panel
Status Asthmaticus
Inhaled Corticosteroids
Phosphodiesterase inhibitor
Randomized trials (x2) - no benefit
over standard 2agonists and/or
corticosteroids
Uncertain benefit in episodes
unresponsive to all other therapy
Status Asthmaticus
IV Theophylline
-Carter, J Peds,
1993
Status Asthmaticus
IV Theophylline
-Carter, J Peds,
1993
“Methylxanthines are NOT
generally recommended.”
-Expert Panel,
NAEPP
Status Asthmaticus
Ketamine
Dissociative anesthetic
Direct bronchodilator
Potentiates catecholamines
Bronchorrhea
Other side effects:
tachycardia
BP
Status Asthmaticus
Ketamine
Adult studies
Case reports:
benefit in avoiding intubation
Randomized trials:
no added benefit
required lower dose due to dysphoria
Children might respond better, less
dysphoria
Status Asthmaticus
Ketamine in Pediatrics
8 case reports:
12 patients - not controlled
8 months - 14 years
Positive affect in all
9/12 intubated
Bolus/Infusion 0.2 - 2.5 mg/kg/hr
Status Asthmaticus
Ketamine in Pediatrics
Bronchodilator:
inhibits cellular Ca++ uptake/release
stabilizes most cell membranes
Clinical effect:
10/13 studies showed improved PEFR in
adults, children
2 adult studies no outcome benefit
Status Asthmaticus
Magnesium Sulfate
*
* *
*
*
* p < .05
-Ciarallo, J Peds,
1996
Status Asthmaticus
Magnesium Sulfate
*
*
*
*
*
* p < .05
-Ciarallo, J Peds,
Status Asthmaticus
Magnesium Sulfate
Results:
ER discharge home:
27% vs 0% control (p = .03)
No difference in hospital stay
No significant side effects
-Ciarallo, J Peds,
1996
Status Asthmaticus
Leukotriene Antagonist
pCO2
PIP
Status Asthmaticus
“Mechanical” Support
BiPAP
Intubation/Mechanical Ventilation
Extracorporeal Life Support
Status Asthmaticus
Non invasive Ventilation
Wear Depends !
Intubation by MD with experience
Have volume ready: hypotension
due to ed intrathoracic pressure
Status Asthmaticus
Intubation
GOALS:
Rest inspiratory muscles
Protect airway
Provide adequate gas exchange NOT
normal exchange
Avoid barotrauma, catastrophe
Status Asthmaticus
Mechanical Ventilation Indications
Coma
Absolute:
Respiratory or cardiac arrest
Antibiotics
Empiric, aggressive hydration
Chest PT
Mucolytics
Sedation??
Evidence-Based Guidelines:
Report Card
Oxygen C
Agonists
Inhaled A+
IV B
Ipratropium A
Corticosteroids A
Methylxanthines D
Report Card: Status Asthmaticus Therapy
Magnesium B+
Ketamine C
HELIOX B-
Inhaled Anesthesia C+
BiPAP C+
Questions??