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EBM PracticeGuideline Asthma PDF
EBM PracticeGuideline Asthma PDF
Steven G. Schauer, DO
Staff Physician, Bayne-Jones Army Community Hospital, Fort Polk, LA
Abstract Peter J. Cuenca, MD
Staff Physician, San Antonio Military Medical Center, San Antonio, TX
racemic albuterol. Noninvasive positive pressure ventilation may Upon completion of this article, you should be able to:
be utilized in patients with moderate to severe exacerbations. 1. Identify and distinguish key features of mild to severe asthma and
triage patients based on initial history and physical examination.
Ketamine may be considered in severe exacerbations, but it should 2. Formulate a broad differential diagnosis of new-onset asthma
not be used routinely. Magnesium sulfate may be beneficial in based on a patient’s age and comorbidities.
severe asthma exacerbations, but routine use for mild to moderate 3. Describe the underlying pathophysiology of asthma and the basic
treatment options that are critical in the management of asthma.
exacerbations is not indicated.
Editor-In-Chief Nicholas Genes, MD, PhD Keith A. Marill, MD Stephen H. Thomas, MD, MPH Research Editor
Andy Jagoda, MD, FACEP Assistant Professor, Department of Assistant Professor, Harvard Medical George Kaiser Family Foundation Michael Guthrie, MD
Professor and Chair, Department of Emergency Medicine, Icahn School School; Emergency Department Professor & Chair, Department of Emergency Medicine Residency,
Emergency Medicine, Icahn School of Medicine at Mount Sinai, New Attending Physician, Massachusetts Emergency Medicine, University of Icahn School of Medicine at Mount
of Medicine at Mount Sinai, Medical York, NY General Hospital, Boston, MA Oklahoma School of Community Sinai, New York, NY
Director, Mount Sinai Hospital, New Medicine, Tulsa, OK
Michael A. Gibbs, MD, FACEP Charles V. Pollack, Jr., MA, MD,
York, NY Professor and Chair, Department FACEP Jenny Walker, MD, MPH, MSW International Editors
of Emergency Medicine, Carolinas Chairman, Department of Emergency Assistant Professor, Departments of Peter Cameron, MD
Associate Editor-In-Chief Medical Center, University of North Medicine, Pennsylvania Hospital, Preventive Medicine, Pediatrics, and Academic Director, The Alfred
Kaushal Shah, MD, FACEP Carolina School of Medicine, Chapel University of Pennsylvania Health Medicine Course Director, Mount Emergency and Trauma Centre,
Associate Professor, Department of Hill, NC System, Philadelphia, PA Sinai Medical Center, New York, NY Monash University, Melbourne,
Emergency Medicine, Icahn School Michael S. Radeos, MD, MPH Ron M. Walls, MD Australia
Steven A. Godwin, MD, FACEP
of Medicine at Mount Sinai, New Assistant Professor of Emergency Professor and Chair, Department of
Professor and Chair, Department Giorgio Carbone, MD
York, NY Medicine, Weill Medical College Emergency Medicine, Brigham and
of Emergency Medicine, Assistant Chief, Department of Emergency
Dean, Simulation Education, of Cornell University, New York; Women’s Hospital, Harvard Medical
Editorial Board University of Florida COM- Research Director, Department of School, Boston, MA
Medicine Ospedale Gradenigo,
William J. Brady, MD Torino, Italy
Jacksonville, Jacksonville, FL Emergency Medicine, New York Scott D. Weingart, MD, FCCM
Professor of Emergency Medicine Hospital Queens, Flushing, New York Associate Professor of Emergency Amin Antoine Kazzi, MD, FAAEM
and Medicine, Chair, Medical Gregory L. Henry, MD, FACEP Associate Professor and Vice Chair,
Emergency Response Committee, CEO, Medical Practice Risk Robert L. Rogers, MD, FACEP, Medicine, Director, Division of
Department of Emergency Medicine,
Medical Director, Emergency Assessment, Inc.; Clinical Professor FAAEM, FACP ED Critical Care, Icahn School of
University of California, Irvine;
Management, University of Virginia of Emergency Medicine, University of Assistant Professor of Emergency Medicine at Mount Sinai, New York,
American University, Beirut, Lebanon
Medical Center, Charlottesville, VA Michigan, Ann Arbor, MI Medicine, The University of NY
Maryland School of Medicine, Hugo Peralta, MD
Peter DeBlieux, MD John M. Howell, MD, FACEP Senior Research Editors Chair of Emergency Services,
Baltimore, MD
Professor of Clinical Medicine, Clinical Professor of Emergency Hospital Italiano, Buenos Aires,
Interim Public Hospital Director Medicine, George Washington Alfred Sacchetti, MD, FACEP James Damilini, PharmD, BCPS Argentina
of Emergency Medicine Services, University, Washington, DC; Director Assistant Clinical Professor, Clinical Pharmacist, Emergency
of Academic Affairs, Best Practices, Department of Emergency Medicine, Room, St. Joseph’s Hospital and Dhanadol Rojanasarntikul, MD
Emergency Medicine Director of
Inc, Inova Fairfax Hospital, Falls Thomas Jefferson University, Medical Center, Phoenix, AZ Attending Physician, Emergency
Faculty and Resident Development,
Church, VA Philadelphia, PA Medicine, King Chulalongkorn
Louisiana State University Health Joseph D. Toscano, MD Memorial Hospital, Thai Red Cross,
Science Center, New Orleans, LA Shkelzen Hoxhaj, MD, MPH, MBA Scott Silvers, MD, FACEP Chairman, Department of Emergency Thailand; Faculty of Medicine,
Francis M. Fesmire, MD, FACEP Chief of Emergency Medicine, Baylor Chair, Department of Emergency Medicine, San Ramon Regional Chulalongkorn University, Thailand
Professor and Director of Clinical College of Medicine, Houston, TX Medicine, Mayo Clinic, Jacksonville, FL Medical Center, San Ramon, CA
Suzanne Peeters, MD
Research, Department of Emergency Eric Legome, MD Corey M. Slovis, MD, FACP, FACEP Emergency Medicine Residency
Medicine, UT College of Medicine, Chief of Emergency Medicine, Professor and Chair, Department Director, Haga Hospital, The Hague,
Chattanooga; Director of Chest Pain King’s County Hospital; Professor of of Emergency Medicine, Vanderbilt The Netherlands
Center, Erlanger Medical Center, Clinical Emergency Medicine, SUNY University Medical Center; Medical
Chattanooga, TN Downstate College of Medicine, Director, Nashville Fire Department and
Brooklyn, NY International Airport, Nashville, TN
Prior to beginning this activity, see the back page for faculty disclosures and CME accreditation information.
Case Presentations asthma is reversible either spontaneously or with
medication.
A 19-year-old college student presents with marked Asthma is defined by its clinical, physiologic,
dyspnea and dysphagia. He reports a history of asthma, and pathologic characteristics, with reversible
for which he takes albuterol as his only medication. Over wheezing as the most common finding. From a
the last 3 days, he has been coughing and wheezing with public health point of view, understanding the
increasing severity. Even though he has been using his underlying causes of asthma and its exacerbants is
albuterol inhaler every 2 hours, there has been minimal key to preventive strategies. From an emergency
to no response. EMS administered a 10-mg albuterol medicine perspective, having clear strategies on how
nebulizer treatment and magnesium sulfate intravenously to best manage acute presentations is key to good
en route to the ED. Upon arrival, the patient appears in outcomes. This issue of Emergency Medicine Practice
extremis, and you wonder if there is something you can do provides an evidence-based review of asthma as
to avoid intubation . . . it relates to emergency department (ED) care and
While establishing IV access and calling respira- establishes best-practice approaches to management.
tory therapy for your first patient, a 24-year-old Hispanic
female with a history of asthma who is 15 weeks pregnant Critical Appraisal Of The Literature
presents with tachypnea and acute shortness of breath
with audible wheezing. She has been taking albuterol and The Ovid MEDLINE®, CINAHL (Cumulative In-
fluticasone at home with no relief of symptoms. She has a dex to Nursing and Allied Health Literature), and
blood pressure of 110/78 mm Hg, heart rate of 110 beats/ PubMed databases were searched using the subject
min, respiratory rate of 40 breaths/min, and pulse oximetry heading asthma. Major terms included: asthma, emer-
of 93% on room air. Physical exam demonstrates accessory gency department, epidemiology, score, treatment, steroid,
respiratory muscle usage, decreased breath sounds, and inhaled, nebulizer, and guideline. The literature search
expiratory wheezing. You recognize that your patient is at was initially limited to relevant titles from the past
risk for deteriorating, and you wonder which interventions 10 years; however, upon finding literature suitable
are safest to use in pregnancy . . . for this review, additional references were added.
Just as you think you are getting control of your first Additionally, searches were conducted using the mi-
2 patients, a 6-year-old girl is brought in by her mother nor headings listed throughout this review. Searches
with the chief complaint of “mild bronchitis.” Her mother identified observational studies, case series, and
reports that the girl’s symptoms began 3 days ago, with randomized trials that were available in English. The
initial upper respiratory infection symptoms that pro- Cochrane Database of Systematic Reviews was also
gressed to nocturnal cough and mild wheezing. She is searched. Reference listings from major textbooks
otherwise well. According to her mother, the girl has 2 to and significant primary literature were reviewed for
3 bouts per year of this “bronchitis” that require emer- relevant articles. National Asthma Education and
gency care. She has had 2 ED visits within the last year, Prevention Program (NAEPP) Expert Panel Report 3
with no prior hospitalization for her bronchitis. Her vital (EPR-3) guidelines were included, and their refer-
signs are: blood pressure of 95/55 mm Hg, heart rate of ences were reviewed.
98 beats/min, respiratory rate of 28 breaths/min, tempera- Existing literature on asthma is very broad and
ture of 37.2°C, and a pulse oximetry of 94% on room air. spans several decades. Surprisingly, there is a lim-
Her physical exam is only significant for end-expiratory ited amount of new research on acute asthma man-
wheezing with no use of accessory muscles and no stridor. agement that impacts clinical decision-making, and
The case seems straightforward, but you wonder if there is many of the treatments used today have been vetted
something you are missing . . . over several decades. In performing this review, we
prioritized data from randomized controlled trials to
Introduction form recommendations and opinions, but such high-
quality evidence was not always available. Given the
Asthma is the most common chronic respiratory rarity of severe asthma, studies involving critically
disease, affecting up to 10% of adults and 30% of ill patients are extremely limited, compared to mild
children in the Western world. Asthma is a world- and moderate asthma. As such, the amount of high-
wide health problem, affecting over 300 million quality prospective data are limited, and we were
individuals of all ages and ethnicities. It is estimated often forced to draw conclusions from literature that
that, worldwide, 250,000 people die prematurely is subject to bias.
each year as a result of asthma.1 Currently, the literature on treatments for mild
Asthma is a chronic inflammatory disorder and moderate asthma is robust, and most mo-
of the lungs that is associated with airway hyper- dalities have been well evaluated. Future studies
responsiveness that leads to recurrent episodes should focus on severe asthma. Reliable methods
of wheezing, shortness of breath, chest tightness, for triaging asthma exacerbations do not currently
and coughing. The airflow obstruction caused by exist, and this is yet another area in need of future
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2013 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.
single, isolated measurements. The literature on PEF Very severe < 150 < 120
rate use in the ED is very mixed; thus, it is challeng-
ing to draw any definitive conclusions from it. In our Reprinted from The American Journal of Emergency Medicine, Vol 28/
opinion, routine PEF measurements should not be issue 7, Chu-Lin Tsai, Sunday Clark, Carlos A. Camargo. Risk stratifi-
cation for hospitalization in acute asthma: the CHOP classification
considered the standard of care at this time.
tree. Copyright (2010), with permission from Elsevier.
Table 5. Suggested Drug Dosing Guide For The Treatment Of Asthma13 (Continued on page 11)
Medication Pediatric Dose Adult Dose Pharmacokinetics Comments
Albuterol nebulizer solution • 0.15 mg/kg (minimum • 2.5-5 mg every 20 • Onset of action: 5-15 • Set gas flow rate at 6-8 L/min
2.5 mg) every 20 min minutes up to 3 doses, min • May mix ipratropium into same
for up to 3 doses, then then 2.5-10 mg every • Peak effect: 0.5-2 h solution
0.15-0.3 mg/kg every 1-4 h as needed • Duration of action:
1-4 h as needed • For continuous use, 3-4 h
• For continuous use, 10-15 mg/h
0.5 mg/kg/h
Albuterol MDI • 4-8 puffs every 20 min • 4-8 puffs every 20 min • Onset of action: 5-15 • Spacer should be used with
(90 mcg/puff) for 3 doses, then as up to 4 h, then every min all pediatric patients and most
needed every 1-4 h 1-4 h after • Peak effect: 25 min adult patients
• Duration of action:
3-4 h
Levalbuterol nebulizer • 0.075 mg/kg (minimum • 1.25-2.5 mg every 20 • Onset of action: 10- • Dosing is similar to albuterol;
solution 1.25 mg) every 20 min min for 3 doses, then 17 min use half the mg dose
up to 3 doses, then 1.25-5 mg every 1-4 h • Peak effect: 1.5 h
0.075-0.15 mg/kg up to • Duration of action:
5 mg every 1-4 h 5-6 h
Levalbuterol MDI • 4-8 puffs every 20 min • 4-8 puffs every 20 min • Onset of action: 5-10 • Spacer should be used with
for 3 doses, then as up to 4 h, then every min all pediatric patients and most
needed every 1-4 h 1-4 h after • Peak effect: 77 min adult patients
• Duration of action:
3-4 h
Epinephrine • 0.01 mg/kg up to 0.3- • 0.3-0.5 mg every 20 • Onset of action: 5-10 • No proven advantage over
1:1000 (1 mg/mL) 0.5 mg every 20 min min for 3 doses, SQ min inhaled SABAs
for 3 doses, SQ • Peak effect: 1 h
• Duration of action:
4h
Terbutaline • 0.01 mg/kg every 20 • 0.25 mg every 20 min • Onset of action: 15 • No proven advantage over
(1 mg/mL) min for 3 doses, then for 3 doses, SQ min inhaled SABAs
every 2-6 h as needed, • Peak effect: 30-60
SQ min
• Duration of action:
90 min to 4 h
Ipratropium bromide (0.5 • Age < 12 y: 1.25 mL • 2.5 mL every 6 h • Onset of action: 15 • May mix with albuterol solution
mg/2.5mL or 0.2 mg/mL every 6 h min in nebulizer
nebulizer) • Age ≥ 12 y: dose as • Peak action: 1-3 h
adult • Duration of action:
3-4
Table 5. Suggested Drug Dosing Guide For The Treatment Of Asthma13 (Continued from page 10)
Medication Pediatric Dose Adult Dose Pharmacokinetics Comments
Ipratropium bromide MDI (18 • 4-8 puffs every 20 min • 8 puffs every 20 • Onset of action: 15 • Use with spacer as indicated
mcg/puff) as needed, for 3 h minutes, as needed, min
for 3 h • Peak effect: 1-2 h
• Duration 2-5 h
Albuterol with ipratropium • 1.5-3 mL every 20 min • 3 mL every 20 min • See individual drugs • May be used for up to 3 h in
nebulizer solution (each 3 for 3 doses, then as for 3 doses, then as initial management
mL contains 0.5 mg ipratro- needed needed • No proven advantage beyond
pium bromide and 2.5 mg 3h
albuterol)
Albuterol with ipratropium • 4-8 puffs every 20 min • 8 puffs every 20 min as • See individual drugs Not applicable
MDI (each puff contains 18 as needed, up to 3 h needed, up to 3 h
mcg ipratropium bromide
and 90 mcg albuterol)
Ketamine • 0.3 mg/kg to maximum • 0.3 mg/kg to maximum • Onset of action: 15 • This is low-dose ketamine NOT
dose of 25 mg IV dose of 25 mg IV sec for intubation; may slow bolus
bolus, then 0.5 mg/kg/h bolus, then 0.5 mg/kg/h • Duration of action: to slow IV push over 5 min
for 2 h for 2 h 5-10 min to reduce risk of dissociative
effects
• Induction dose: 1-2 mg/kg
Magnesium sulfate • 25-75 mg/kg up to 2 g • 2g IV over 20 min • Onset of action: im- • No benefit in mild to moder-
IV over 20 min mediate ate exacerbations; reserve for
• Duration of action: severe exacerbations
30 min
Prednisone • 1-2 mg/kg divided into • 40-80 mg/day divided • Peak plasma: 1-3 h • Outpatient “burst” 3-10 days,
2 doses PO, maximum into 1-2 doses • Duration of action: depending on severity
dose 60 mg/day biologic 8-36 h
Methylprednisolone • 1-2 mg/kg divided into • 40-80 mg/day divided • Peak effect: 1-2 h • Outpatient “burst” 3-10 days,
2 doses, maximum into 1-2 doses • Duration of action: depending on severity
dose 60 mg/day biologic 30-36 h
Prednisolone • 1-2 mg/kg divided into • 40-80 mg/day divided • Peak plasma: 1 h • Outpatient “burst” 3-10 days,
2 doses PO, maximum into 1-2 doses PO • Duration of action: depending on severity
dose 60 mg/day biologic 18-36 h
Dexamethasone • 0.6 mg/kg, to maximum • 16 mg for 2 doses • Peak plasma: 1-2 h • Give 1 dose in ED and 1 dose
dose of 16 mg, for 2 • Duration of action: in the next 1-2 days
doses biologic 36-54 h
Abbreviations: IV, intravenous; PO, by mouth; SABA, short-acting beta agonist; SQ, subcutaneous.
Table adapted from National Asthma Education and Prevention Program Expert Panel Report 3 guidelines13 with revisions made based on literature
discussed.
Clinical Pearls For Ventilator Management Image courtesy of Philip Mason, MD.
• Maintain low to zero PEEP; do not go any higher
than 5 cm H2O unless absolutely indicated.
• If the initial respiratory rate does not allow ad- Figure 3. Breath-Stacking On The Ventilator
Tracing
Figure 1. Illustration Of Breath-Stacking On
The Ventilator Tracing
The arrow on the top demonstrates what a full expiration looks like on
the ventilator tracing. This is what is ideal for the patient. The arrow on
the bottom demonstrates an incomplete expiration prior to the initiation
of the next breath. Breath-stacking will lead to an auto-PEEP phenom- Arrows point to breath-stacking on a dynamic ventilator breath tracing.
enon with subsequent clinical effects. Image courtesy of Philip Mason, MD.
Aminophylline
Aminophylline is a combination of theophylline and Time- And Cost-Effective
ethylenediamine. Its main pharmacological action Strategies
is relaxation of bronchial smooth muscle. Multiple
Cochrane reviews in both children and adults have 1. Ensuring expedited follow-up care and commu-
found no benefit to standard care with the addition nicating with the patient’s primary care provider
of aminophylline.140-142 Given the lack of supporting are important for good patient care as well as
evidence, prolonged time to onset, and toxic risks of cost savings. Using cost-of-illness modeling,
theophylline, we recommend against this therapy. adequate and sufficient treatment are key to
earning annual savings.176
Heliox 2. Impoverished urban children suffer dispropor-
Heliox has gained interest for the treatment of both tionately from asthma, and they under use pre-
upper and lower airway obstruction. It is less dense ventive asthma medications. Administration of
than air or oxygen and thus provides more laminar preventive asthma medication at school by the
flow in obstructed airways.143 Evidence regarding school nurse each school day has been shown
the efficacy of heliox in the literature is sparse. The to reduce symptoms and decrease healthcare
most recent randomized controlled trials have found utilization in urban children with asthma.177
that heliox-driven albuterol may be a useful adjunct Discharge instructions from the ED specifically
therapy for adult asthma patients with severe asth- instructing the patient to have the school nurse
ma exacerbation after other therapies have been at- administer outpatient medication can lead to
tempted. Current studies have shown that albuterol overall healthcare cost savings.
nebulized with heliox offers no clinical benefit over 3. Use of metered-dose inhalers with spacers in
standard therapy in severe pediatric asthma.144,145 If place of wet nebulizers to deliver albuterol to
available, it may be considered as an adjunct therapy treat children with mild to moderate asthma
in severe asthma exacerbations when other therapies exacerbations in the ED can yield significant cost
have failed. The mixture (typically 70% helium, 30% savings for hospitals and, by extension, to both
oxygen) limits its use in hypoxic patients. the healthcare system and families of children
with asthma.178,179
Long-Acting Beta Agonists 4. A multidisciplinary approach to patient care
Long-acting beta-adrenoceptor agonists (more incorporating clinical pharmacy services in the
specifically beta agonists, with duration > 8-12 h) are ED may improve disease state management and
usually prescribed for moderate-to-severe persistent medication cost savings through generic pre-
asthma in the chronic management setting. They scription of asthma medications.180
are designed to reduce the need for short-acting 5. Use of racemic albuterol instead of levalbuterol
beta agonists, as they have a duration of action of is most cost-effective, as the differences are clini-
approximately 12 hours, making them candidates cally insignificant and racemic albuterol is much
for sparing high doses of corticosteroids. However, cheaper.
1. “The treatment seemed straightforward; I 3. “The patient didn’t have any questions, so I
didn’t think their home situation was any of didn’t think she really wanted to hear all the
my business.” intricate details. “
Psychosocial problems need to be identified Prescription of steroids in the treatment of acute
and addressed as part of asthma management, asthma can lead to the following complications:
because, even with best practice, these problems avascular necrosis, mood changes, visual
place patients at an increased risk of dying. complaints, and infection. A provider treating
Family psychosocial problems and financial patients with steroids must be diligent in
problems are associated with increased risk of explaining the potential side effects of steroids.
mortality for patients aged > 31 years but not for The informed consent process, documentation,
younger patients. Males were at increased risk of and close monitoring of patients are critical to
mortality from asthma exacerbation overall, but avoid potential litigation.
females with family problems are at greater risk
than males with family problems. Alcohol use 4. “I was concerned about the fetal side effects
increased the risk of mortality for individuals and figured that short-acting beta agonist
who received only verbal instructions without a therapy was sufficient.”
written action plan. Maternal asthma is associated with an increased
risk of spontaneous abortion. Standard medical
2. “I thought the longer-acting medication would treatment of acute asthma does not increase the
help reduce the need for repeat treatments.” risk of congenital anomalies in the offspring
Clinical studies of long-acting beta agonists when taken during the first trimester of
compared to placebo in asthma patients using pregnancy.
variable doses of inhaled corticosteroids have
raised the issue of mortality risk in patients 5. “I thought I would see how the patient re-
with asthma who are taking regular long- sponded to standard therapies before starting
acting beta agonists. Long-acting beta agonists noninvasive positive-pressure ventilation.”
added to inhaled corticosteroids reduces Noninvasive ventilation (NIV) has been
asthma-related hospitalizations compared to shown to be effective in a wide variety of
inhaled corticosteroids alone, and there is no clinical settings; however, reports of NIV in
statistical increase in mortality. However, long- asthma patients are scarce. There are a few
acting beta agonist treatment without inhaled prospective clinical trials reporting promising
corticosteroids does increase mortality risk in results in favor of the use of NIV in a severe
asthma. Healthcare providers must understand asthma attack. A trial of NIV prior to invasive
the essential need for adequate dosing of inhaled mechanical ventilation seems acceptable and
corticosteroids to control airway inflammation.
may benefit patients by decreasing the need for 8. “Steroids from the discharge pharmacy seemed
intubation and by supporting pharmaceutical much easier.”
treatments. Although selecting the appropriate Early administration of steroid therapy is
patients for NIV use is a key factor in successful essential. Current literature suggests that early
NIV application, how to distinguish such administration decreases hospitalization rates
patients is still quite controversial. If this and bounce-back rates. When treating for
technology is going to be employed, reaching for acute exacerbations, steroid therapy should be
it early will likely yield more benefit. administered early.
6. “I knew the patient was sick, but ETCO2 9. “PEF rate values were improved, so discharge
seemed sufficient.” seemed appropriate.”
In adult asthma patients with acute Proper triage of acute exacerbations must be
exacerbations, concordance between ETCO2 based on complete clinical and psychosocial
measured by capnography and PaCO2 measured factors as a package. There is no single clinical
by blood gas is high. However, capnography is factor that can be relied upon for triaging.
not a replacement of blood gas as an accurate Additionally, lack of historical risk factors does
means of assessing alveolar ventilation in acute not equal lack of morbidity and mortality risk.
asthma.
10. “It seemed that if we could have held off a
7. “We had trouble getting IV access, so I thought little bit longer, the patient’s course would turn
the nebulized therapy would suffice.” around.”
The use of IV magnesium sulfate (in addition When intubation is clinically indicated, the
to beta agonists and systemic steroids) in the emergency clinician should proceed without
treatment of acute asthma improves pulmonary delay. Waiting to intubate when intubation
function and reduces the number of hospital is clinically indicated will lead to increased
admissions for children; it only improves likelihood of procedural complications and
pulmonary function for adults. Though the respiratory arrest. We recommend that only
use of nebulized magnesium sulfate appears to the most experienced provider perform the
produce benefits for adults, the routine use of procedure, given the increased need for first-
this form of magnesium sulfate should not be pass success.
considered standard of care at this point.
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