Favor continuous nebulization to decrease the chance of admission when compared to intermittent dosing
Nebulizer
Intermittent: 2.5-5mg q20min, three doses are traditionally given back to back, then repeat as needed.
Continuous: 0.5mg/kg/hr (max 15mg/hr)
MDI
4-8 puffs q20min given in first hour, then q1-4hr as needed
Intermittent: 2.5-5mg q20min, three doses are traditionally given back to back, then repeat as needed.
Continuous: 0.5mg/kg/hr (max 15mg/hr)
4-8 puffs q20min given in first hour, then q1-4hr as needed
0.25-0.5mg q20min, given with the first three doses of albuterol, it is shown to reduce admission.
Should be given in the first hour with effects to reduce admission
Dexamethasone
0.6 mg/kg PO or IV (max 16 mg); consider 2nd dose 24-36hrs later.
PO and IV have equal efficacy. Giving the IV form by mouth is typically better tolerated by young children (same dosing)
Both 1 and 2 dose regimens as effective as prednisone or prednisolone in children 
Prednisone
1-2mg/kg/day (60mg max) in one or two divided doses for 3-5 days
Methylprednisolone
1mg/kg IV q 4–6hr
Only use IV if cannot tolerate PO since equal effectiveness between dosing routes
0.6 mg/kg PO or IV (max 16 mg); consider 2nd dose 24-36hrs later.
PO and IV have equal efficacy. Giving the IV form by mouth is typically better tolerated by young children (same dosing)
Both 1 and 2 dose regimens as effective as prednisone or prednisolone in children 
PO and IV have equal efficacy. Giving the IV form by mouth is typically better tolerated by young children (same dosing)
1-2mg/kg/day (60mg max) in one or two divided doses for 3-5 days
1mg/kg IV q 4–6hr
Only use IV if cannot tolerate PO since equal effectiveness between dosing routes
Dose: 50mg/kg IV, max 2-4 g over 20 mins with close blood pressure monitoring
Smooth muscle relaxant
Duration of action approximately 20 min
In patients with moderate to severe<unk>  there is a decreased rate of admission with an NNT of 2
Epinephrine
1:1000 0.01mg/kg (max 0.3mg) IM, repeat as needed
Terbutaline
Given SQ, usual dose 0.01mg/kg up to 0.3mg.
Longer-acting beta2-agonist promoting bronchodilation
1:1000 0.01mg/kg (max 0.3mg) IM, repeat as needed
Given SQ, usual dose 0.01mg/kg up to 0.3mg.
Longer-acting beta2-agonist promoting bronchodilation
Non-invasive ventilation
Consider as alternative to intubation
Alleviates muscle fatigue which leads to larger tidal volumes
Maximize inspiratory support
Delta pressure 10
PEEP >4
May benefit from ketamine or dexmedetomidine to mildly sedate and allow the interface
Consider as alternative to intubation
Alleviates muscle fatigue which leads to larger tidal volumes
Maximize inspiratory support
Delta pressure 10
PEEP >4
May benefit from ketamine or dexmedetomidine to mildly sedate and allow the interface
Delta pressure 10
PEEP >4
Push pull (bolus) fluids prior to intubation to maximize the patient's preload and ideally decrease the chance of the patient arresting
Consider induction with ketamine
Provides bronchodilation and sedation however it does promote secretions
Ketamine is the preferred induction agent for intubation in an<unk> tic.
Dosing 1-2 mg/kg
Ventilation of<unk> tic patients requires deep sedation
Benzos, ketamine (1 mg/kg/hr)
Ventilation settings
Assist-control ventilation
Resp rate
Start slow to avoid air-trapping and allow for longer expiration time
Consider I:E ratio of 1:2 or 1:3
Plateau pressure ideally <30
May require "permissive hypoventilation" and permissive hypercarbia and acidosis
Low peak pressure/avoidance of breath stacking more important than correcting CO2 
Tidal volume 6-8cc/kg ideal wt
PEEP >4
Flow rate 80-100L/min
Keep FiO2 minimum to achieve SpO2 > 90%
Use bronchodilators even when intubated
Many patients require a continuous paralytic infusion for the first 24+ hrs of intubation
Provides bronchodilation and sedation however it does promote secretions
Ketamine is the preferred induction agent for intubation in an<unk> tic.
Dosing 1-2 mg/kg
Benzos, ketamine (1 mg/kg/hr)
Assist-control ventilation
Resp rate
Start slow to avoid air-trapping and allow for longer expiration time
Consider I:E ratio of 1:2 or 1:3
Plateau pressure ideally <30
May require "permissive hypoventilation" and permissive hypercarbia and acidosis
Low peak pressure/avoidance of breath stacking more important than correcting CO2 
Tidal volume 6-8cc/kg ideal wt
PEEP >4
Flow rate 80-100L/min
Keep FiO2 minimum to achieve SpO2 > 90%
Start slow to avoid air-trapping and allow for longer expiration time
Consider I:E ratio of 1:2 or 1:3
Low peak pressure/avoidance of breath stacking more important than correcting CO2
Acute asthma exacerbation 
Upper Airway diseases
COPD exacerbation
Allergic rhinitis and sinusitis
Acute chest syndrome
Large Airway Obstruction
Acute dyspnea
Foreign body aspiration