Ipratropium bromide causes bronchodilation by blocking muscarinic cholinergic receptors Adding anticholinergics to SABA is associated with improved pulmonary function and, reduced hospitalization rates for those with severe exacerbations, particularly using multiple-dose protocols Many protocols recommend its use for moderate severity as well Corticosteroids block formation of potent inflammatory mediators and reduce airway inflammation Systemic corticosteroids are associated with improved pulmonary function and reduced hospitalizations The effect on reducing hospitalizations is time dependent, maximized with early administration A common metric regarding optimal asthma care is administration of systemic corticosteroids within 60 minutes of arrival Administration of systemic corticosteroids is also associated with fewer ED relapse visits and hospitalization at such return visits Systemic corticosteroid options include dexamethasone, prednisone, prednisolone, or methylprednisolone Dexamethasone has recently become more popular with recent studies and systematic reviews reporting similar outcomes and less vomiting compared to prednisone or prednisolone, though there was heterogeneity among treatment regimens Dexamethasone, prednisone, and prednisolone have good oral bioavailability and tolerability, and oral route has similar effectiveness compared to IV route If patients are in severe distress or actively vomiting, methylprednisolone or dexamethasone (IV or intramuscular) should be considered Other than these exceptions, oral corticosteroids are preferred for milder exacerbations For patients discharged from the ED, those who received dexamethasone may not require additional doses considering its longer duration of action compared to prednisone/prednisolone; those who received prednisone/prednisolone are usually prescribed treatment for to days After initial therapy, it is important to reassess the need for continued and adjunctive medications Response to therapy can be categorized as good, incomplete, or poor Patients with good response have improvement with mild features and can be observed briefly and subsequently discharged if not requiring frequent SABA or having other indications for admission Those with incomplete or poor response continue to have moderate or severe features They should receive frequent, possibly continuous, albuterol, and adjunctive therapies such as magnesium sulfate, heliox, or parenteral bronchodilator therapy should be considered Many studies have evaluated use of medications considered adjunctive (e.g., continuous albuterol, magnesium sulfate, heliox) in comparison to initial standard albuterol treatment, though, in practice, most clinicians administer them after insufficient improvement with multiple albuterol and ipratropium treatments Adjunctive therapies such as magnesium sulfate and heliox can be administered in conjunction with ongoing inhaled bronchodilators, and timing may vary according to severity Frequent reassessments during initial treatment for those with severe exacerbations, anticipating the need for adjunctive therapy, are essential to avoid delays Continuous nebulized albuterol treatment is recommended for patients with severe exacerbations or poor response to initial inhaled bronchodilator treatment A systematic review found that continuous albuterol was associated with greater improvement in peak expiratory flow rate (PEFR) and lower hospitalization rate, particularly among those with moderate or severe exacerbations, with no increase in adverse effects Magnesium sulfate causes bronchodilation by relaxing respiratory smooth muscle It is administered as a single IV bolus with a recommended dose of 50 to 75 mg/kg (maximum g) Use of this therapy has been associated with improved pulmonary function and reduced hospitalization rates Magnesium can be administered early in the course of patients with more severe exacerbations Others utilize magnesium after insufficient improvement from standard acute therapy with multiple SABA and ipratropium doses, and such patients often require hospitalization (frequently intensive care) although some patients may improve enough to allow discharge Ultimately, disposition following magnesium administration is determined by the severity of the presentation and the response to treatment Heliox is a mixture of helium and oxygen, thought to improve drug delivery in obstructed airways due to its lower density and airflow resistance The commonly used mixtures (helium:oxygen) are 70:30 or 80:20, but use in patients with significant hypoxemia may be limited Contraindications for Heliox are pneumothorax, pneumopericardium, or pneumoperitoneum; therefore a chest radiograph (CXR) should be obtained prior to initiation Parenteral β-agonists are also options to consider for adjunctive therapy Epinephrine administered intramuscularly may be an option for severe exacerbations, particularly as initial treatment for patients with significant airway obstruction when delivery of inhaled medications to the lower airways may be limited Epinephrine autoinjectors used to treat anaphylaxis are readily available in most EDs and can be used Terbutaline may be administered subcutaneously or intravenously as a bolus and continued as an IV infusion Although commonly included in many pediatric protocols for refractory asthma, pediatric studies regarding use are limited Noninvasive ventilatory support (CPAP or BiPAP) may benefit patients tiring from increased work of breathing and with impending respiratory failure Pediatric studies are limited but suggest that it is generally well tolerated While some studies suggest that it may reduce need for ICU admission, in practice, most patients who require noninvasive ventilatory support are treated in an ICU setting CXRs are not routinely indicated for acute asthma exacerbations in children Wheezing is a common symptom of asthma and pneumonia in children, therefore determining which patients warrant imaging can be challenging Data regarding children of all ages with wheezing and fever who had CXR for possible pneumonia, suggest that approximately 5% will have radiographic findings of pneumonia However, the potential risks of CXR include radiation exposure and false-positive results leading to unnecessary antibiotic therapy In general, patients with a typical asthma exacerbation not routinely need imaging given this low rate of abnormal findings In a patient with mild to moderate respiratory distress, the decision to perform a CXR may be deferred until reassessment after initial treatment; focal abnormal breath sounds may have improved suggesting atelectasis as opposed to pneumonia Clinical Indications for Discharge or Admission In general, children requiring frequent albuterol (generally defined as more frequent than every to hours) or having persistent hypoxemia require admission Other reasons for admission include significant dehydration, infection requiring inpatient treatment or monitoring, or medical history that may impact the respiratory system (e.g., cardiac disease, neuromuscular disorder, or metabolic disorder) Most patients requiring frequent inhaled bronchodilator therapy or adjunctive therapy (e.g., parenteral bronchodilators) will require hospitalization Protocols regarding which therapies require an ICU setting vary by institution Patients discharged should be encouraged to follow up with their primary care providers (PCPs) within to days Discharge instructions should include information about care following the acute visit and may include formulation of an asthma action plan This provides an opportunity to assist patients with management during future exacerbations and to encourage partnership with PCPs for ongoing discussions and modifications of asthma care Inhaled steroids should be continued for patients currently taking them, and clinicians should strongly consider prescribing them from the ED when indicated Patients with or more days/nights of symptoms and/or albuterol use per week likely have chronic asthma severity in the “persistent” range and inhaled steroids are recommended Data suggest that many patients treated for acute asthma in EDs meet criteria for persistent chronic asthma severity, yet prescriptions are not provided or patients are noncompliant with therapy Therefore, the ED visit for asthma represents an opportunity to improve outcomes for these children ASPIRATION PNEUMONIA CLINICAL PEARLS AND PITFALLS Aspiration pneumonitis refers to chemical injury and inflammation of lung tissue after inhalation of foreign material, whereas aspiration pneumonia refers to infection of lung tissue following pneumonitis Patients at risk for aspiration pneumonia include those with impaired neurologic status, technology dependence, oropharyngeal dysfunction, and gastrointestinal dysmotility Initial chest radiographs may be normal following aspiration episodes Treatment with antibiotics is generally reserved for patients with significant respiratory impairment and signs of infection or complicating medical history Treatment with corticosteroids is not routinely indicated Current Evidence Aspiration of foreign material into the lung can result in inflammation and impaired lung function Aspiration pneumonitis (also referred to as chemical pneumonitis) refers to chemical injury and inflammation of lung tissue from inhaled foreign material, with sterile acidic gastric contents being the most common source Aspiration pneumonia refers to infection of lung tissue following inhalation of foreign material, often due to bacteria from the oropharynx The pathophysiology of pulmonary disease following aspiration has been studied in animal models These studies have demonstrated that a relatively large volume acidic inoculum will induce pathologic changes within minutes including atelectasis, peribronchial hemorrhage, and pulmonary edema There is an appreciable inflammatory response on pathology with polymorphonuclear cells and fibrin along with hyaline membrane deposits These responses are mediated through multiple proinflammatory cytokines Aspiration of hydrocarbons is covered separately in Chapter 102 Toxicologic Emergencies ... a bolus and continued as an IV infusion Although commonly included in many pediatric protocols for refractory asthma, pediatric studies regarding use are limited Noninvasive ventilatory support... benefit patients tiring from increased work of breathing and with impending respiratory failure Pediatric studies are limited but suggest that it is generally well tolerated While some studies