Giving oral corticosteroids and repeated doses of bronchodilators in the first 60 minutes of care reduces hospitalization rates substantially.³
MDI/spacer versus nebulization: Beta-agonist treatment with MDI/spacer is clinically equivalent with fewer side-effects and shorter ED length of stay as compared with nebulization.² Patients with severe respiratory distress improve more quickly with bronchodilators nebulized continuously vs intermittent treatment every 20 minutes.⁴ Use a large-volume nebulizer for continuous therapy or a small-volume nebulizer with repeat doses given “back-to-back”.⁴
Ipratropium: 2-3 doses in the first hour of treatment yields greater improvement and decreases hospitalization.⁵ Benefits appear to be greatest in severe respiratory distress but may also aid patients in moderate distress.⁵
Corticosteroids: Early administration of steroids with initial beta-agonists shortens respiratory distress and decreases hospitalization.³ Oral dexamethasone or prednisone/prednisolone are comparably effective;⁶ Dexamethasone is the preferred due to less vomiting and better tolerance.⁶ A one or two-day course of dexamethasone appears to be as effective as a five-day course of oral prednisone/prednisolone.⁶
Magnesium sulfate: Give to children in impending respiratory failure as part of initial management OR to those who remain in moderate to severe respiratory distress after the first hour of bronchodilator treatment in addition to continuous bronchodilator therapy.⁷