PEDIATRICS
A 6-year-old boy with a history of asthma presents to the ED in severe res-
piratory distress. In the ED, he has already received inhaled bronchodila-
tors, steroids, and magnesium, without any significant improvement. His
RR is 45, O 2 saturation is 89% on a 100% FiO 2 albuterol neb. What additional
medication should he receive?
Epinephrine 1:1000, subcutaneously or intramuscularly, at a dose of 0.01
mg/kg (maximum single dose of 0.3 mg).ASTHMA
(See also Chapter 10, “Thoracic and Respiratory Emergencies.”)
Asthma falls into the spectrum of atopic disease that includes eczema and
seasonal/food allergies. Patients with asthma have chronic inflammation of
the airways. Acute flares of asthma result from the triadof airway inflamma-
tion (often with mucus plugging), bronchial hyperresponsiveness, and inter-
mittent reversible airway obstruction. Triggersof asthma flares include viral
URIs, cold weather, exercise, cigarette smoking, and other allergens (eg, dust
mites, cockroaches).
SYMPTOMS/EXAM
■ Episodes of wheezing with respiratory distress
■ Persistent cough: 30% of children with asthma have cough-variant asthma
and may not wheeze.
DIFFERENTIAL
Wheezing does not always mean asthma! Other causes of wheezing include
GERD, CHF, foreign body aspiration, pneumonia, bronchiolitis.
DIAGNOSIS
■ Mainly a clinical diagnosis
■ Peak expiratory flow rate (PEFR), CXR, and ABG may be helpful (see
Chapter 10).
TREATMENT
■ O 2 as needed, to correct hypoxemia
■ Inhaledβ-agonists (albuterol)
■ Inhaled anticholinergics (ipratropium)
■ Oral or IV steroids
■ Epinephrine SQ/IM for severe exacerbations
■ Adjunctive therapies include ketamine and heliox.
Infectious Disorders
BACTERIALTRACHEITIS
■ Bacterial superinfection of the trachea causing rapid and severe respiratory
symptoms
■ Median age is 4 years oldbut wide age range
Asthma triad: Airway
inflammation (often with
mucous plugging), bronchial
hyperresponsiveness, and
intermittent reversible airway
obstruction