Improving Management of Severe Asthma: BiPAP and Beyond

Paper 1  - Improving management of severe asthma: BiPAP and beyond Batabyal RA, O’Connell K. Clin Ped Emerg Med 2018 Mar;19(1):69-75. 

DOI:10.1016/j.cpem.2018.02.007

• Most children with asthma can be controlled with inhaled beta-2 agonists, ipratropium, and steroids.
• Epinephrine is the KEY drug in allergic patients with shortness of breath after an exposure.
• Therapy for severe or unresponsive asthma includes:
• Continuous inhaled Beta-2 agonists
• Recommended dosing: nebulized route in children ≤ to 12 years of age: 0.15-0.3 mg/kg up to 10 mg every 1-4 hours as needed, or 0.5 mg/kg/hour by continuous nebulization. 
• Magnesium Sulfate
• Recommended dosing: 25-75 mg/kg/dose IV (max dose 2 g) over 20 minutes. 
• Terbutaline
• Recommended dosing of terbutaline:
• Subcutaneous: 0.01 mg/kg/dose (max 0.25 mg) every 20 minutes for three doses
• IV: 0.1 to 10 mcg/kg/min as a continuous infusion prepared in 0.9% normal saline or dextrose.
• Most patients are started at a dose of 1 mcg/kg/min with the dose titrated to effect.
• If starting at doses lower than 1 mcg/kg/min, a loading dose of 10 mcg/kg IV over 10 minutes can be given to more rapidly achieve effect.
• Epinephrine
• IM has rapid onset
• Indicated for severe disease and associated allergic reactions 
• High Flow Nasal Oxygen
• Might be helpful, data not conclusive. 
• Noninvasive ventilation
• Might be helpful in some patients to decrease the work of breathing.
• Non-invasive ventilation is contraindicated in patients with:
• Altered mental status
• Hypotension
• Respiratory arrest
• Inability to protect airway
• Recommended settings: Aim initially for an adequate tidal volume of 5-7 mL/kg with an FiO2 titrated to achieve an SpO2 of greater than 90%. Initial IPAP/EPAP settings of 10/5 cm H2O are usually adequate, but should be titrated to necessary effect. 
• Heliox
• Recommended in severe asthma not responding to standard therapy, though the data are mixed.
• Standard heliox cylinders contain a mixture of 79% helium and 21% oxygen, but concentrations can be adjusted to a concentration of 70% helium and 30% oxygen.
• As the concentration of oxygen increases, the benefits of laminar flow decrease.
• Heliox therapy is not appropriate for patients with status asthmaticus and hypoxia requiring greater than 30% FiO2. 
• Ketamine
• Data is poor. Not currently recommended 
• Aminophylline
• Limited data and serious side effects, not recommended
• Inhaled Anesthetics

May be an option in selected cases of severe refractory status asthmaticus. It is an expensive therapy and supportive data are lacking.