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خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : -2 مورد

Medications other than inhaled beta agonists for treatment of acute asthma exacerbations in children <12 years of age*[1]

Medications other than inhaled beta agonists for treatment of acute asthma exacerbations in children <12 years of age*[1]
Inhaled bronchodilator (anticholinergic)
Ipratropium bromide nebulizer solution (500 mcg/2.5 mL)
  • <20 kg – 250 mcg/dose.
  • ≥20 kg – 500 mcg/dose.
  • Every 20 minutes for 3 doses, then as needed. May combine with albuterol for intermittent or continuous nebulizer treatment.
Ipratropium bromide MDI with spacer (17 mcg/actuation)
  • 4 to 8 puffs every 20 minutes as needed for up to 3 hours. Use VHC spacer; add mask in children <4 years.
Systemic glucocorticoids
Dexamethasone
  • Oral (preferred) – 0.3 to 0.6 mg/kg once daily for 1 to 2 days (maximum dose: 8 to 16 mg/day).
  • IM, IV – 0.3 to 0.6 mg/kg once daily for 2 days (maximum dose: 8 to 16 mg/day).
Prednisone or prednisoloneΔ
  • Oral – 1 to 2 mg/kg/day in 2 divided doses for 3 to 5 days◊ (maximum dose: 60 mg/day).
Methylprednisolone
  • Oral (preferred), IV (succinate formulation) – 1 to 2 mg/kg/day in 2 divided doses for 5 days◊ (maximum dose: 60 mg/day).
  • For patients requiring ICU management, may administer a loading dose of 2 mg/kg IV once, then 0.5 to 1 mg/kg every 6 hours for 5 days◊ (maximum dose: 60 mg/day).
Systemic beta2-agonists§
Epinephrine (1 mg/mL)
  • IM or SUBQ – 0.01 mg/kg once; may repeat every 20 minutes as needed for up to 3 doses until clinical improvement is demonstrated (maximum dose: 0.5 mg/dose or 0.5 mL of 1 mg/mL solution). If there is evidence of anaphylaxis, IM administration is preferred, and more frequent administration may be warranted.
Terbutaline (1 mg/mL)¥
  • IM or SUBQ – 0.01 mg/kg once; may repeat every 20 minutes for up to 3 doses then every 2 to 6 hours as needed until clinical improvement is demonstrated or IV terbutaline is initiated (maximum dose: 0.4 mg/dose or 0.4 mL of 1 mg/mL solution).
  • IV – Initial bolus of 10 mcg/kg over 10 minutes, followed by a continuous infusion of 0.3 to 0.5 mcg/kg/min; may titrate in increments of 0.1 to 0.5 mcg/kg/min every 30 minutes until desired effect is achieved or adverse effects are observed. Typical maximum dose is 2 to 3 mcg/kg/min; however, doses as high as 6 to 10 mcg/kg/min have been described in the ICU setting.
Other treatment
Magnesium sulfate
  • IV – 50 mg/kg (0.2 mmol/kg) administered as a single dose over 20 minutes (range: 25 to 75 mg/kg [0.1 to 0.3 mmol/kg]; maximum dose: 2 grams [approximately 8 mmol])‡.

ED: emergency department; ICU: intensive care unit; IM: intramuscular; IV: intravenous; MDI: metered-dose inhaler; ODT: orally disintegrating tablet; SUBQ: subcutaneous; VHC: valved holding chamber.

* Also refer to separate UpToDate topic reviews and table on recommended doses of beta-agonist medications for treatment of acute asthma exacerbations in children <12 years of age.

¶ Continuous nebulized albuterol and ipratropium are typically administered via a large-volume nebulizer or vibrating mesh nebulizer.

Δ Useful formulations of prednisolone include concentrated oral liquids and ODTs. For additional detail, refer to the drug monographs included with UpToDate or local product information.

◊ A longer course (eg, 7 to 10 days) may be beneficial for patients who have a severe exacerbation that is slow to respond to treatment or patients who have had more than one exacerbation requiring oral glucocorticoids in the previous 2 months. In addition, patients whose control regimen includes oral glucocorticoids may benefit from a >10-day course.

§ Typically, epinephrine or terbutaline is reserved for patients who present to the ED with a severe exacerbation with markedly diminished aeration. May give IM or SUBQ epinephrine or terbutaline, but not both. IV terbutaline is reserved for severely ill patients who are poorly responsive to conventional therapy. Alternative treatment options for these patients include noninvasive positive pressure ventilation and high-flow nasal cannula. Systemic beta2-agonist treatment requires noninvasive cardiopulmonary monitoring, such as that available in a critical care setting. Orally administered systemic beta2-agonists are not recommended.

¥ Some centers reserve terbutaline for ICU care and do not use it in the ED.

‡ Maximum dose of magnesium sulfate of up to 2.5 grams IV (approximately equal to 10 mmol) may be considered.[2]
References:
  1. Scarfone RJ, Fuchs SM, Nager AL, Shane SA. Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma. Pediatrics 1993; 92:513.
  2. Scarfone RJ, Loiselle JM, Joffe MD, et al. A randomized trial of magnesium in the emergency department treatment of children with asthma. Ann Emerg Med 2000; 36:572.

Courtesy of Richard Scarfone, MD, FAAP.

Additional data from: US Department of Health and Human Services. Expert panel report 3: Guidelines for the diagnosis and management of asthma. NIH Publication No. 07-4051. August 2007 available at https://www.ncbi.nlm.nih.gov/books/NBK7232/pdf/Bookshelf_NBK7232.pdf (accessed March 12, 2020).
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