Respiratory


Asthma Exacerbation: Adults

Mild
  1. Supplemental Oxygen to maintain O2 Sat > 90%
  2. Albuterol inhaled :
    • (90 micrograms/dose metered-dose inhaler)  4-8 puffs  q 20 minutes for up to 4 hrs, then q 1-4 hrs when required; OR
    • 2.5 to 5 mg nebulized q 20 minutes x 3 doses, followed by 2.5 to 10 mg q 1-4 hrs when required; or 10-15 mg/hour nebulized continuously
  3. Prednisone : 40-80 mg/day orally given in 1-2 divided doses
    Methylprednisolone : 60-80 mg orally once daily
    Dexamethasone : 16 mg orally once daily
Moderate
  1. Supplemental Oxygen to maintain O2 Sat > 90%
  2. Albuterol inhaled :
    • (90 micrograms/dose metered-dose inhaler)  4-8 puffs  q 20 minutes for up to 4 hrs, then q 1-4 hrs when required; OR
    • 2.5 to 5 mg nebulized q 20 minutes x 3 doses, followed by 2.5 to 10 mg q 1-4 hrs when required; or 10-15 mg/hour nebulized continuously
       
  3. Ipratropium bromide inhaled : 500 micrograms nebulized given in combination and dosed with each administration of short-acting beta-2 agonist (usually every 20 minutes for 3 doses and then when required)
     
  4. Prednisone : 40-80 mg/day orally given in 1-2 divided doses
    Methylprednisolone : 60-80 mg orally once daily
    Dexamethasone : 16 mg orally once daily
     
  5. Magnesium sulfate : 2 g intravenously as a single dose given over 20 minutes
  6. Try BiPAP
    • Pt probably getting tired and are getting close to or are already losing inspiratory effort
  7. Consider Ketamine (1mg/kg/hr) before intubation
    • bronchodilator and relaxation effect

With impending respiratory failure:

  1. ICU
  2. +/- Mechanical Ventilation
    • For patients who are refractory to therapy and remain in severe respiratory distress.
    • Ventilatory management strategies often include:
      • LOW RR,
      • LOW tidal volumes,
      • High Inspiratory flow rates,
      • Avoidance of ventilator-applied positive end-expiratory pressure (PEEP).
  3. +/- IV ABx

 

Severe
  1. ICU admission plus oxygen plus consider assisted ventilation:
    Supplemental oxygen should be given by nasal cannulae or nonrebreather mask to achieve arterial oxygen saturation of >90%.
     
  2. Albuterol inhaled : 2.5 to 5 mg nebulized q 20 minutes x 3 doses, followed by 2.5 to 10 mg q 1-4 hrs when required; or 10-15 mg/hour nebulized continuously
    -- AND --
    Ipratropium bromide inhaled : 500 micrograms nebulized given in combination and dosed with each administration of short-acting beta-2 agonist (usually every 20 minutes for 3 doses and then when required)
     
  3. Hydrocortisone sodium succinate : 100 mg intravenously every 8 hours -OR-
    Prednisone : 40-80 mg/day orally given in 1-2 divided doses -OR-
    Methylprednisolone : 60-80 mg orally once daily
     
  4. Magnesium sulfate : 2 g intravenously as a single dose given over 20 minutes
     
  5. Heliox: 80:20 or 70:30 helium to oxygen ratios have been used.
    Coadministration of a helium-oxygen gas mixture (heliox) and bronchodilators may be helpful in selected patients with respiratory failure but is controversial.
     
  6. Try BiPAP
    • Pt probably getting tired and are getting close to or are already losing inspiratory effort
    • Settings: 8 iPAP/2 ePAP
  7. Consider Ketamine (1mg/kg/hr)  before intubation
    • bronchodilator and relaxation effect
       
  8. Mechanical Ventilation
    • For patients who are refractory to therapy and remain in severe respiratory distress.
    • Ventilatory management strategies often include:
      • LOW RR,
      • LOW tidal volumes,
      • High Inspiratory flow rates,
      • Avoidance of ventilator-applied positive end-expiratory pressure (PEEP).
         
  9. IV ABx

 

 

Asthma Exacerbation: Child

  1. Supplemental Oxygen to maintain O2 Sat > 92%
  2. Albuterol SVN
    Small Volume Neb., 0.15 mg/kg/dose, Can repeat q20min x 3 doses, then q1-4h PRN,
    Max dose: 5mg
     
  3. Albuterol MDI
    Metered dose inh., 0.25 puffs/kg
    Max: 10 puffs
     
  4. Ipratropium Bromide
    < 20 kg: 250 μg/dose
    > 20 kg: 500 μg/dose
    Combine with first dose albuterol Tx
    -AVOID- MDI w/ Hx of nut allergy

     
  5. Continous Albuterol Neb
    5-10 kg: dose 10 mg/hr
    10-20 kg: dose 15 mg/hr
    > 20 kg: dose 20 mg/hr
     
  6. Steroids:
    • Prednisone/Prednisolone PO
      2 mg/kg, Administer to those who fail initial inhalation therapy
      Max dose: 60 mg
       
    • Dexamethasone
      0.6 mg/kg
      Max: 16 mg
       
    • Methylprednisolone
      2 mg/kg IV
       
  7. NEB Steroid (budesonide 0.5mg)
    Racemic Epi 11.25mg NEB   or   NEB Terbutiline
    Benadryl 1.25mg/kg
    Ibuprofen 10mg/kg
    (Arachidonic acid blocker - Block inflammatory pathway)

     
  8. Epinephrine 1:1000 IM/SC
    0.01 mL/kg
    Max: 0.4mg
     

No response to initial Tx of Impending Resp. Failure:

  1. Terbutaline SC
    0.01 mg/kg
    Max: 0.4 mg (0.4 ml of 1 mg/ml sol)
    -OR-
  2. Terbutaline IV
    10 μg/kg bolus over 10 min, then 0.3 - 0.5 μg/kg/min
     
  3. Theophylline
    5 mg/kg IV loading dose, followed by 1 mg/kg/hr continuous infusion
     
  4. Magnesium Sulfate IV/IM
    50 mg/kg/dose over 20 min q4-6h
    Give NS Bolus first to avoid hypotension
    Max: 2 g
     
  5. Ventilation plus transfer to ICU
    Indications for intubation and mechanical ventilation:
     Clinical symptoms of exhaustion, cyanosis, or drowsiness with hypoxemia and hypercapnia.

     Intubation is preferred before the onset of respiratory arrest.

    Fluid replacement will be required in these patients, as they are frequently fluid depleted, and initiation of positive pressure ventilation may be accompanied by hypotension.

    Noninvasive ventilation may be used as a rescue therapy to avoid intubation. Continuous positive airways pressure, CPAP, or bi-level non-invasive ventilation can be applied using either a nasal or full-face mask interface.

    Sedation is occasionally necessary for patient tolerance, but should be used with caution
     

ABx:

  • Azithromycin: 10 mg/kg orally once daily on the first day, followed by 5 mg/kg once daily for 4 days
  • Clarithromycin: 15 mg/kg/day orally given in divided doses every 12 hours, maximum 1000 mg/day
  • Erythromycin base: 30-50 mg/kg/day orally given in divided doses every 6 hours

COPD Exacerbation

1. Oxygen
  • Long-term oxygen therapy reduces COPD mortality. The primary goal of long-term oxygen therapy is to increase the baseline PaO2 to 60 mm Hg or the arterial oxygen saturation (SaO2) to 90% at rest.
  • Criteria for long-term oxygen therapy are a PaO2 55 mm Hg, an SaO2 88%, or a PaO2 between 56 and 59 mm Hg when pulmonary hypertension, cor pulmonale, or polycythemia are present.
2. Inhaled β-agonists and anticholinergics
  • Albuterol inh: 2.5 mg neb every 20 minutes for up to 2 hours or until clinical improvement in dyspnea and gas exchange noted, or development of adverse effects
    +
  • Ipratropium bromide inhaled : (17 micrograms/dose inhaler), 34 micrograms (2 puffs) every 2-4 hours via a spacer; OR 500 micrograms nebulized three to four times daily with doses given 6-8 hours apart

     
  • Limit the use of antihistamines, antitussives, and decongestants.
  • Expectorants are not of clear benefit.
3. Systemic steroids
  • Prednisone 40 mg PO
  • Methylprednisolone 125 mg IV
  • Dexamethasone : 16 mg orally once daily OR  4-8mg IV
4. Antibiotics (Indicated in cases with increased sputum volume and purulence)
  • cefuroxime axetil : 500 mg orally twice daily for 3-10 days; 750 mg intravenously every 8 hours
  • amoxicillin/clavulanate : 875 mg orally twice daily for 3-10 days 
  • trimethoprim/sulfamethoxazole : 160/800 mg orally twice daily for 3-10 days
  • levofloxacin : 500 mg orally once daily for 3-10 days, or 750 mg orally once daily for 5 days
  • ciprofloxacin : 500 mg orally twice daily for 7-10 days
  • moxifloxacin : 400 mg orally/intravenously once daily for 3-10 days
  • ampicillin/sulbactam : 1.5 to 3 g intravenously every 6 hours  
  • ticarcillin/clavulanate : 3.1 g intravenously every 6 hours  
  • piperacillin/tazobactam : 3.375 g intravenously every 6 hours  
  • azithromycin : 500 mg orally on day one, followed by 250 mg once daily for 4 days
  • clarithromycin : 500 mg orally twice daily for 3-10 days
  • vancomycin : 500-1000 mg intravenously every 12 hours
Non-Invasive Ventilation
  • Early NIIV is very effective to avoid intubation in severe exacerbations
  • Contraindicated with respiratory arrest, hemodynamic instability, or altered mental status

Indications for Invasive Mechanical Ventilation

Severe dyspnea with use of accessory muscles and paradoxical abdominal motion
Respiratory rate >35 breaths/min
Life-threatening hypoxemia: PaO2 <50 mm Hg (<5.3 kPa) or PaO2/fraction of inspired oxygen <200 mm Hg
Severe acidosis (pH <7.25) and hypercapnia (PaCO2 >60 mm Hg or >8.0 kPa)
Respiratory arrest
Somnolence, impaired mental status
Cardiovascular complications (hypotension, shock, heart failure)
Noninvasive positive pressure ventilation failure

Indications & Relative Contraindications for Noninvasive Ventilation

Selection criteria Moderate to severe dyspnea with use of accessory muscles and paradoxical abdominal motion
Moderate to severe acidosis (pH 7.35) and/or hypercapnia (PaCO2 >6.0 kPa, 45 mm Hg) 
Respiratory frequency > 25 breaths/min
Exclusion criteria (any) Respiratory arrest
Cardiovascular instability (hypotension, arrhythmias, myocardial infarction)
Change in mental status; uncooperative patient
High aspiration risk
Viscous or copious secretions
Recent facial or gastroesophageal surgery
Craniofacial trauma
Fixed nasopharyngeal abnormalities
Burns
Extreme obesity
 
Consider concomitant CHF, PNA, PTX, PE, lobar atelectasis
Smoking cessation and home oxygen are the only 2 interventions shown to lower mortality
 

Croup

  1. Supplemental Oxygen to maintain O2 Sat > 92%
      Oxygen: 8 to 10 L/min blow-by
      Oxygen: 100% by nonrebreather mask
     
  2. Epinephrine, racemic: (2.25% solution) 0.5 mL/kg in 3 mL NS NEB over 15 min. q 1-2h

    Epinephrine inhaled: (1:1000 solution of L-epinephrine) 5 mL undiluted nebulized as a single dose 
  3. Steroids
    • Dexamethasone
      0.3-0.6 mg/kg IV, IM, or PO once (effect lasts 2-3 days)
      Max: 16 mg
       
    • Budesonide inhaled:
      2 mg nebulized as a single dose

       
  4. Intubation:
    Indicated in children progressing to asynchronous chest wall and abdominal movement, fatigue, and signs of hypoxia (pallor or cyanosis) and hypercarbia (decreased level of consciousness secondary to rising PaCO2).

    Becoming increasingly uncommon (in only 1% to 3% of children admitted with croup) and performed as rapid sequence induction in a controlled setting with experienced personnel and equipment. 

    Advisable to have a selection of endotracheal tubes of smaller sizes at hand, as subglottic edema may cause difficulty when intubating with a standard sized endotracheal tube