Bronchospasm
Signs and symptoms include: expiratory wheeze, prolonged expiration, increased inflation pressures, desaturation, hypercapnia, upsloping capnograph trace, silent chest. Can occur alone or as part of another problem.
Wheeze: pulmonary oedema; ARDS; laryngospasm
Raised airway pressure: obstruction of larynx, trachea or bronchi; decreased lung compliance; pneumothorax
Salbutamol
Nebuliser: Child <5 yr, 2.5 mg; Adult and >5 yr 5 mg (Remove HME filter OR nebulise downstream)
i.v. bolus: Adult 250 µg diluted, slowly; Child 1–23 months 5 µg.kg⁻¹ once over 5 min; Child 2–17 years 15 µg.kg⁻¹ once over 5 min (max. 250 µg)
Adult i.v. infusion: 5–20 µg.min⁻¹
Child i.v. infusion: 0.5–1 µg.kg⁻¹.min⁻¹ (max. 20 µg.min⁻¹)
Ipratropium
Neb: 2–12 yr 0.25 mg; Adult 0.5 mg
Adrenaline
Neb: Child 0.5 ml of 1:1000
Neb: Adult 5 ml of 1:1000
i.m.: <6 mo 50 µg; <6 yr 120 µg; <12 yr 250 µg; Adult 500 µg
Slow i.v. bolus: 0.1–1 µg.kg⁻¹ (Adult 10–100 µg)
Magnesium
i.v. over 20 min: 50 mg.kg⁻¹ (Adult 2 g)
Ketamine
Bolus: Adult 20 mg
i.v. infusion: 1–3 mg.kg⁻¹.hr⁻¹
Aminophylline
i.v. over 20 min: 5 mg.kg⁻¹ (omit if already on theophylline)
i.v. infusion: <9 yr 1 mg.kg⁻¹.hr⁻¹; <16 yr 0.8 mg.kg⁻¹.h⁻¹; Adult 0.5 mg.kg⁻¹.h⁻¹
Hydrocortisone
4 mg.kg⁻¹ (Adult 200 mg)
Consider tracheal intubation and tracheal toilet.
Use nasogastric tube to aspirate gastric contents.
Increase expiratory time to allow complete expiration.
Pressure control ventilation may be better.
Be alert to 'breath stacking'.
Permissive hypercapnia may be appropriate.