Pediatric Respiratory Pediatric Respiratory EmergenciesEmergencies

Mohammed Al Faifi, MD.Mohammed Al Faifi, MD.Director, Emergency Out-Reach ProgramDirector, Emergency Out-Reach ProgramKing Faisal Specialist Hospital & Research King Faisal Specialist Hospital & Research

Centre Centre Riyadh, KSARiyadh, KSA

Kuwait, Oct. 2011Kuwait, Oct. 2011

Pediatric Respiratory Pediatric Respiratory EmergenciesEmergencies

Part 1Part 1Emergency Management Emergency Management

of Asthma of Asthma

Data on visits to EDs by childrenData on visits to EDs by children

– – 1 -19 years of age with moderate/severe asthma1 -19 years of age with moderate/severe asthma

– – 3 months to 2 years of age with bronchiolitis3 months to 2 years of age with bronchiolitis

– – 3 months to 3 years of age with croup3 months to 3 years of age with croup

Knapp et al. Pediatrics 2008

QUALITY OF CARE OF ED RESPIRATORY ILNESSQUALITY OF CARE OF ED RESPIRATORY ILNESS

ResultsResultsCorticosteroidsAntibioticsRadiographs

69% of the 405,000visits for moderate/severe asthma

31% of the estimated317,000 annualcroup visits

53% of the estimated228,000 annual visitsfor bronchiolitis

72% of bronchiolitisvisits

32% of croup visits

Knapp et al. Pediatrics 2008

ConclusionsConclusions

Physicians treating children with Asthma, bronchiolitis Physicians treating children with Asthma, bronchiolitis and croup In USA Emergency Departments are and croup In USA Emergency Departments are

under usingunder using known effective treatments and known effective treatments and overusingoverusing ineffective or unproven therapies and diagnostic tests.ineffective or unproven therapies and diagnostic tests.

Knapp et al. Pediatrics 2008

Pediatric Respiratory Pediatric Respiratory EmergenciesEmergencies

Part 1Part 1Emergency Management Emergency Management

of Asthma of Asthma

IntroductionIntroduction Asthma is the most common chronic disease Asthma is the most common chronic disease

seen in childrenseen in children Emergency department (ED) visits by children Emergency department (ED) visits by children

with acute asthma are a common with acute asthma are a common occurrence occurrence

The overall goal of asthma care in the ED is to The overall goal of asthma care in the ED is to integrate with home, outpatient, and integrate with home, outpatient, and inpatient care whenever possible inpatient care whenever possible

Recognition of high-risk patients with acute Recognition of high-risk patients with acute asthma is essential.asthma is essential.

HistoryHistory Initial history is brief, focusedInitial history is brief, focused

• Duration of symptomsDuration of symptoms• Severity of symptomsSeverity of symptoms• Medication use Medication use

More comprehensive history followsMore comprehensive history follows• TriggersTriggers • FeverFever• Systemic Review Systemic Review

http://aware.instablogs.com/entry/sentenced-a-mother-who-allowed-her-three-year-old-son-to-smoke/

Past Medical HistoryPast Medical History Previous wheezingPrevious wheezing Prior admissions for wheezingPrior admissions for wheezing Prior admissions to ICUPrior admissions to ICU Chronic lung diseaseChronic lung disease

Physical ExaminationPhysical Examination Level of consciousnessLevel of consciousness Vital signsVital signs Degree and symmetry of wheezingDegree and symmetry of wheezing Inspiratory and expiratory ratioInspiratory and expiratory ratio Accessory muscle useAccessory muscle use

Differential DiagnosisDifferential Diagnosis BronchiolitisBronchiolitis Foreign body aspirationForeign body aspiration Gastroesophageal refluxGastroesophageal reflux Cystic fibrosisCystic fibrosis AnaphylaxisAnaphylaxis

Pulmonary Index Score*Pulmonary Index Score*ScoreScoreR.R*R.R*WheezingWheezing††I/E RatioI/E Ratio

Acc.Muscle Acc.Muscle use use OO22 Sat.Sat.

00<< 30 30NoneNone2:12:1NoneNone99-10099-100

1131 - 4531 - 45End expirationEnd expiration1:11:1++96 -9896 -98

2246 - 6046 - 60Entire Entire expirationexpiration

1:21:2++++93- 9593- 95

33> 60> 60Inspiration and Inspiration and expiration expiration without without stethoscopestethoscope

1:31:3++++++< 93< 93

* For patients aged 6 or older: through 20, score 0; 21 through 35, score 1; 36 through 50, score 2; > 50, score 3.† If no wheezing due to minimal air entry, score 3.

Pulse OximetryPulse Oximetry Noninvasive and inexpensiveNoninvasive and inexpensive Can help to predict the need for Can help to predict the need for

hospitalizationhospitalization Obtain for moderately to severely ill Obtain for moderately to severely ill

childrenchildren Supplement with oxygen if SaSupplement with oxygen if SaOO22 < <

92%92%

CXRsCXRs

CXRs for First Time WheezersCXRs for First Time Wheezers 371 children > age 1371 children > age 1 94% CXRs normal94% CXRs normal 20/21 abnormal films would have 20/21 abnormal films would have

been identified by: been identified by: • RR > 60RR > 60• HR> 160HR> 160 • FeverFever• Focal examFocal exam

Gerschel, N Engl J Med 1983

Chest RadiographsChest Radiographs

Focal findingsFocal findings FeverFever Severe diseaseSevere disease

Treatment OptionsTreatment Options BetaBeta22--agonists agonists

• Inhaled (nebulizer vs. metered-dose inhaler) Inhaled (nebulizer vs. metered-dose inhaler) • Subcutaneously Subcutaneously • IntravenouslyIntravenously

Corticosteroids Corticosteroids • OrallyOrally • NebulizedNebulized• IntramuscularlyIntramuscularly• IntravenouslyIntravenously

Ipratropium bromideIpratropium bromide Magnesium sulfateMagnesium sulfate

BetaBeta22-Agonist Delivery-Agonist Delivery BetaBeta22--agonists remain the standard of agonists remain the standard of

care for treatment of acute asthmacare for treatment of acute asthma They should be administered every 20 They should be administered every 20

mins, in the first hour of caremins, in the first hour of care Delivery by SVN or MDI with holding Delivery by SVN or MDI with holding

chamber are each reasonable optionschamber are each reasonable options Steps should be taken to insure optimal Steps should be taken to insure optimal

drug deliverydrug delivery

BetaBeta22-Agonist Optimizing Delivery-Agonist Optimizing Delivery

Small particlesSmall particles MouthpieceMouthpiece Low inspiratory flow rateLow inspiratory flow rate Breath-holdingBreath-holding

http://arcusepito.com/view.php?video=7aREyqfRO2Y&feature=youtube_gdata_player&title=Aero-Chamber+101

Ipratropium BromideIpratropium Bromide An anticholinergicAn anticholinergic Low lipid solubilityLow lipid solubility Less than 1% absorbedLess than 1% absorbed Safe, inexpensiveSafe, inexpensive Most studies show that IB plus a Most studies show that IB plus a BetaBeta22 agonist agonist

is superior to is superior to BetaBeta22 agonist alone agonist alone

Ipratropium BromideIpratropium Bromide

Group 1A, PA, PA, PGroup 2A, IA, PA, PGroup 3A, IA, IA, I

02040

Time (mins.)

Schuh, et al. J.Pediatrics 1995;126:639-645Schuh, et al. J.Pediatrics 1995;126:639-645

Ipratropium BromideIpratropium Bromide Ipratropium plus Ipratropium plus BetaBeta22 agonist is superior to agonist is superior to

BetaBeta22 agonist alone agonist alone Multi-dose ipratropium is superior to single Multi-dose ipratropium is superior to single

dosedose Safe, inexpensiveSafe, inexpensive Peak effects are in 40-60 minutesPeak effects are in 40-60 minutes

Schuh, et al. J.Pediatrics 1995;126:639-645Schuh, et al. J.Pediatrics 1995;126:639-645

Ipratropium Bromide Ipratropium Bromide RecommendationsRecommendations

For children with a moderate or moderate-toFor children with a moderate or moderate-to--severe severe exacerbation or for those already receiving exacerbation or for those already receiving BetaBeta22 agonist agonist therapy therapy ::

• 250-500250-500 ug of ipratropium bromide by ug of ipratropium bromide by nebulization to be administered concurrently with nebulization to be administered concurrently with the albuterol treatmentsthe albuterol treatments

Scarfone, et al,Scarfone, et al, Pediatrics 1993; 92: 513-518 Pediatrics 1993; 92: 513-518

Randomized, double-blind, placeboRandomized, double-blind, placebo

75 children in the ED with a moderate to 75 children in the ED with a moderate to severe asthma attacksevere asthma attack

2mg/kg oral prednisone vs. placebo2mg/kg oral prednisone vs. placebo

Scarfone, et al Scarfone, et al Oral CorticosteroidsOral Corticosteroids:: Decreases hospitalization rateDecreases hospitalization rate Effective within 4 hoursEffective within 4 hours Augments Augments BetaBeta22--agonistsagonists

therapytherapy

Conclusions:Conclusions:

Oral vs IV Steroid Oral vs IV Steroid

Randomized, double-blinded, placeboRandomized, double-blinded, placebo 49 Children in ED with moderate to 49 Children in ED with moderate to

severe acute asthmasevere acute asthma 2mg/kg methylprednisolone: Oral vs IV2mg/kg methylprednisolone: Oral vs IV

Barnett, et al. Ann Emerg Med, 1997; 29 :212-217

Barnett, et al.Barnett, et al.

After 4 hours, there were no differences After 4 hours, there were no differences between the two groups with respect to:between the two groups with respect to:• Hospitalization rateHospitalization rate• FEV1FEV1• Pulmonary index scorePulmonary index score• Oxygen saturationOxygen saturation• Respiratory rateRespiratory rate

•ResultsResults

Oral Prednisone vs. Oral Dexamethasone

533 children in ED with mild, moderate, or severe asthma

All got q 20 min RA and IB, in first hour Prednisone - 2 mg/kg in ED - 1 mg/kg for 4 days Dexamethasone

- 0.6 mg/kg in ED - 0.6 mg/kg for 1 dose, on day 2

Qureshi F .J Pediatrics 2001

Oral Prednisone vs Oral Dexamethasone

Pred.Pred. Dex.Dex. Admit, from ED 12% 11% Admit, from ED 12% 11% Relapse 7% 7%Relapse 7% 7% Admit, after relapse 17% 20% Admit, after relapse 17% 20% Symptoms at 10 days 21% 22% Symptoms at 10 days 21% 22% Vomited in ED Vomited in ED 3% 0.3 3% 0.3 Noncompilance Noncompilance 4% 0.44% 0.4

Qureshi F .J Pediatrics 2001

Moderate AsthmaModerate AsthmaTreatment RecommendationsTreatment Recommendations

BetaBeta22 agonists may be delivered by SVNs or MDIs agonists may be delivered by SVNs or MDIs with holding chamberswith holding chambers

Ipratropium bromide should be given as a single Ipratropium bromide should be given as a single dose or concurrently with first 3 dose or concurrently with first 3 BetaBeta22 agonist agonist treatmentstreatments

Prednisone should be given early ASAPPrednisone should be given early ASAP -If emesis • Methylprednisolone IV • Dexamethasone: orally or IM

Albuterol nebulization or Albuterol nebulization or MDI MDI PrednisonePrednisone11

OO22 If Pulse Ox If Pulse Ox << 92% 92% Albuterol q20-30 mins.Albuterol q20-30 mins.Ipiatropium with albuterol Ipiatropium with albuterol

Marked Marked ImprovementImprovement

No improvementNo improvement

Discharge Discharge homehome

HospitalizeHospitalize

Continue albuterol q30 Continue albuterol q30 mins.mins.

Slightly Slightly improvedimproved

DispositiDispositionon

Management of Moderate Asthma

DispositionDisposition Discharge :Discharge : PEF > 70% predicted, PEF > 70% predicted, Symptoms are minimal or absent, Symptoms are minimal or absent, Sufficient medications can be prescribed and Sufficient medications can be prescribed and

maintainedmaintained Outpatient care can be established within a several-Outpatient care can be established within a several-

days time framedays time frame EDUCATION.. EDUCATION..

DispositionDispositionObserved for 30 to 60 minutes for symptom Observed for 30 to 60 minutes for symptom

recurrencerecurrence hospitalization :hospitalization : prior history of a sudden, severe exacerbation prior history of a sudden, severe exacerbation prior intubation or ICU Admissionprior intubation or ICU Admission ≥ ≥ two hospitalizations in the past year two hospitalizations in the past year current steroid use or recent wean from steroids current steroid use or recent wean from steroids medical or psychiatric comorbidity medical or psychiatric comorbidity low socioeconomic status or urban residence low socioeconomic status or urban residence

POST EMERGENCY DEPARTMENT CAREPOST EMERGENCY DEPARTMENT CARE

Short-term MedicationsShort-term Medications - Beta-agonist Therapy - Beta-agonist Therapy - Corticosteroids - Corticosteroids - Inhaled steroids- Inhaled steroids Education Education

Pulmonary Index Score*Pulmonary Index Score*ScoreScoreR.R*R.R*WheezingWheezing††I/E RatioI/E Ratio

Acc.Muscle Acc.Muscle use use OO22 Sat.Sat.

00<< 30 30NoneNone2:12:1NoneNone99-10099-100

1131 - 4531 - 45End expirationEnd expiration1:11:1++96 -9896 -98

2246 - 6046 - 60Entire Entire expirationexpiration

1:21:2++++93- 9593- 95

33> 60> 60Inspiration and Inspiration and expiration expiration without without stethoscopestethoscope

1:31:3++++++< 93< 93

* For patients aged 6 or older: through 20, score 0; 21 through 35, score 1; 36 through 50, score 2; > 50, score 3.† If no wheezing due to minimal air entry, score 3.

Severe AsthmaSevere Asthma No wheezing 3No wheezing 3 Unable to speak Unable to speak Dyspnea 2Dyspnea 2 Markedly prolonged expiratory phase Markedly prolonged expiratory phase

33 Significant work of breathing withSignificant work of breathing with Retractions 2Retractions 2 Requires oxygen 3Requires oxygen 3

Severe AsthmaSevere Asthma

Oxygen (consider non-rebreather)Oxygen (consider non-rebreather) Inhaled beta2-agonistInhaled beta2-agonist Inhaled ipratropium bromideInhaled ipratropium bromide Intravenous corticosteroids ASAPIntravenous corticosteroids ASAP

Initial managementInitial management

OxygenOxygen Simple face maskSimple face mask

• An oxygen flow rate of 6-10 An oxygen flow rate of 6-10 L/min should provide an L/min should provide an oxygen concentration of 35-oxygen concentration of 35-60%60%

• Limitations: open exhalation Limitations: open exhalation ports allow for the inspiration ports allow for the inspiration of room air and exhaled of room air and exhaled carbon dioxide is rebreathedcarbon dioxide is rebreathed..

OxygenOxygen Non. re-breathing face maskNon. re-breathing face mask

Modifications allow for greater oxygen Modifications allow for greater oxygen delivery to the patient. These delivery to the patient. These include:include:

Exhalation ports serving as one-Exhalation ports serving as one-way valves.way valves.

A reservoir bag with a one-way A reservoir bag with a one-way valve that diverts oxygen-poor valve that diverts oxygen-poor exhaled gases thereby exhaled gases thereby maintaining a mix of almost pure maintaining a mix of almost pure oxygen.oxygen.

With flow of 10-12 L/min and With flow of 10-12 L/min and proper fitting mask, oxygen proper fitting mask, oxygen concentrations > 90% can concentrations > 90% can usually be achieved.usually be achieved.

Subcutaneous TerbutalineSubcutaneous Terbutaline

Uncooperative, anxious young childrenUncooperative, anxious young children Very poor inspiratory flow or aerationVery poor inspiratory flow or aeration Poor response to initial nebulized albuterolPoor response to initial nebulized albuterol

Continuously Nebulized AlbuterolContinuously Nebulized Albuterol AdvantagesAdvantages::

• Easier to adhere toEasier to adhere to• Less respiratory therapy timeLess respiratory therapy time• SafeSafe• May benefit sicker patientsMay benefit sicker patients

DisadvantagesDisadvantages::• Patients may go unobservedPatients may go unobserved• Claustrophobic maskClaustrophobic mask

CorticosteroidsCorticosteroids

IV Methylprednisolone ASAPIV Methylprednisolone ASAP

Magnesium SulfateMagnesium Sulfate Is It SafeIs It Safe

• Mild side effects during infusion:Mild side effects during infusion:Facial flushing, nausea, dry mouth, malaiseFacial flushing, nausea, dry mouth, malaise

• Significant adverse effects have not been Significant adverse effects have not been reportedreported

• Hypotension and cardiac conduction Hypotension and cardiac conduction disturbances are seen only with serum disturbances are seen only with serum magnesium levels > 8 mg/dlmagnesium levels > 8 mg/dl

Magnesium SulfateMagnesium Sulfate ConclusionsConclusions

• The routine administration of magnesium to The routine administration of magnesium to moderately to severely ill asthmatic children as moderately to severely ill asthmatic children as an adjunct to initial treatment with albuterol an adjunct to initial treatment with albuterol and corticosteroids was not efficacious.and corticosteroids was not efficacious.

• Future studies will be needed to determine the Future studies will be needed to determine the optimal optimal dosedose of magnesium, the optimal of magnesium, the optimal duration duration of infusion, and the subgroup of of infusion, and the subgroup of asthmatic children most likely to benefit from asthmatic children most likely to benefit from magnesium.magnesium.

• Severely ill asthmatics experience the greatest Severely ill asthmatics experience the greatest benefit from magnesiumbenefit from magnesium

IV IV BetaBeta22 Agonists Agonists Recommendations:Recommendations:

• Not recommended as a first-line agent Not recommended as a first-line agent even for severely ill childreneven for severely ill children

• For severely ill who are poorly For severely ill who are poorly responsive to initial measuresresponsive to initial measures

IV TerbutalineIV Terbutaline 1010 ug/kg over 10 minutes; infusion 0.5 ug/kg over 10 minutes; infusion 0.5

ug/kg/minug/kg/min Increase by 0.2 ug/kg/min to max of Increase by 0.2 ug/kg/min to max of

5ug/kg/min5ug/kg/min Largely empiric Largely empiric titrate to effecttitrate to effect Expect side effects at therapeutic dosesExpect side effects at therapeutic doses Decrease infusion rate by 50% if patient is Decrease infusion rate by 50% if patient is

receiving theophyllinereceiving theophylline

IV IV BetaBeta22 Agonists Agonists Potential ToxicitiesPotential Toxicities

TachycardiaTachycardia DysrhythmiaDysrhythmia HypertensionHypertension Myocardial Myocardial

ischemiaischemia

HyperglycemiaHyperglycemia HypokalemiaHypokalemia RhabdomyolysisRhabdomyolysis Lactic acidosisLactic acidosis

Severe Asthma Severe Asthma

Arterial blood gasArterial blood gas HelioxHeliox IntubationIntubation -ketamine-ketamine -Decompress stomache-Decompress stomache -Beware of barotrauma-Beware of barotrauma -Permissive hypercapnia-Permissive hypercapnia -Low tidal volumes and peak pressures -Low tidal volumes and peak pressures -Slow rate, no PEEP, I/E ratio=1/3 -Slow rate, no PEEP, I/E ratio=1/3 Inhaled nitic oxideInhaled nitic oxide Nakagawa et al, J Pediatr 2000Nakagawa et al, J Pediatr 2000

Other Considerations

Supplemental Oxygen

Vital Signs & oxygen saturation

Severe Status Asthmaticus

IV Terbutaline infusion

2mg/kg IV Methylprednisolone

0.01cc/kg of subcutaneous terbutaline

Continue with approach to moderately ill patient

0.15mg/kg albuterol by nebulization 250-500 micgm Ipratropium Bromide

Continuously nebulized albuterol

75mg/kg IV Magnesium sulfate

Good responsePoor response

Clinical Role of MDI’sClinical Role of MDI’sWhen used with a (mask) spacer device,When used with a (mask) spacer device,multiple pediatric studies show MDImultiple pediatric studies show MDIeffectiveness comparable to nebulization therapyeffectiveness comparable to nebulization therapy

• • Chou et al. Arch Pediatr Adolesc Med 1995Chou et al. Arch Pediatr Adolesc Med 1995• • Williams et al. Pediatr Emerg Care 1996Williams et al. Pediatr Emerg Care 1996• • Leversha et al. J Pediatr 2000Leversha et al. J Pediatr 2000• • Delgado et al. Arch Pediatr Adolesc Med 2003Delgado et al. Arch Pediatr Adolesc Med 2003

MDI / Spacer TipsMDI / Spacer Tips• • 10 puffs or detergent wash to eliminate electrostatic charge 10 puffs or detergent wash to eliminate electrostatic charge

of of new spacernew spacer

– – Avoids initial 70% delivery reductionAvoids initial 70% delivery reduction• • Shake MDI before each puff, administer 1 puff at aShake MDI before each puff, administer 1 puff at atime one minute apart, 5 tidal breaths per pufftime one minute apart, 5 tidal breaths per puff– – 6 puffs / rx for acute exacerbation (Q 20” x 3)6 puffs / rx for acute exacerbation (Q 20” x 3)– – 2 puffs / rx for maintenance (Q 3-6 hours)2 puffs / rx for maintenance (Q 3-6 hours)• • Count total puffs per MDI (200 std.)Count total puffs per MDI (200 std.)– “– “shake” or “float” tests unreliableshake” or “float” tests unreliable

Dexamethasone in AsthmaDexamethasone in Asthma • • Random, non-blinded, 3-16 years, N = 42Random, non-blinded, 3-16 years, N = 42 • • IM dexamthasone, 0.3 mg/kg (up to 15IM dexamthasone, 0.3 mg/kg (up to 15 mg), effective as 3 day course of oralmg), effective as 3 day course of oral prednisone, 2 mg/kg/dayprednisone, 2 mg/kg/day • • Oral dexamethsone 0.6 mg/kg (up to 16Oral dexamethsone 0.6 mg/kg (up to 16 mg) x 2 days vs. pred x 5 days. Similarmg) x 2 days vs. pred x 5 days. Similar efficacy fewer side effects.efficacy fewer side effects. Klig et al. J Asthma 1997 and Qureshi et al. J Klig et al. J Asthma 1997 and Qureshi et al. J

Pediatr 2001Pediatr 2001

Magnesium SulfateMagnesium Sulfate • • Bronchodilation through smooth Bronchodilation through smooth

musclemuscle relaxationrelaxation • • Inhibits cellular calcium uptakeInhibits cellular calcium uptake • • Inhibits histamine releaseInhibits histamine release

Mg IV vs. PlaceboMg IV vs. Placebo • • RCT (double blind), placebo, 1-18 yrs,RCT (double blind), placebo, 1-18 yrs, N=54N=54 • • Mg 75 mg/kg IV over 20 minutes vs.Mg 75 mg/kg IV over 20 minutes vs. placebo after 1st albuterolplacebo after 1st albuterol • • No different in PFTs or admit rateNo different in PFTs or admit rate • • No adverse effects or BP changes with MgNo adverse effects or BP changes with Mg Scarfone et al. Ann Emerg Med 2000Scarfone et al. Ann Emerg Med 2000

IV Magnesium Sulfate in AsthmaIV Magnesium Sulfate in Asthma • • Meta-analysis of 5 RCTs (with placebo)Meta-analysis of 5 RCTs (with placebo) • • 182 pediatric patients with moderate to severe182 pediatric patients with moderate to severe asthmaasthma • • Received beta agonists and steroidsReceived beta agonists and steroids • • Mg prevents hospitalization (NNT = 4)Mg prevents hospitalization (NNT = 4) • • Short term PFTs and clinical scores improvedShort term PFTs and clinical scores improved • • ? Dose, 25-75 mg/kg over 20 minutes? Dose, 25-75 mg/kg over 20 minutes Cheuk et al. Arch Dis Child 2005Cheuk et al. Arch Dis Child 2005

PICU Case ReportsPICU Case Reports • • 3 children in status asthmaticus3 children in status asthmaticus • • Maximized traditional therapyMaximized traditional therapy • • Failure to improve after 2-3 hoursFailure to improve after 2-3 hours • • BiPAP delivered an average of 12-17 hoursBiPAP delivered an average of 12-17 hours • • Resolution of hypercarbia, and improvedResolution of hypercarbia, and improved clinical stateclinical state • • 2/3 used continuous IV ketamine as adjunct2/3 used continuous IV ketamine as adjunct Olugbenga A, et al. Pediatr Crit Care Med 2002Olugbenga A, et al. Pediatr Crit Care Med 2002

Factors Associated with LongFactors Associated with Long Asthma TherapyAsthma Therapy • • Previous ICU admitPrevious ICU admit • • Baseline sat ≤ 92%Baseline sat ≤ 92% • • Higher ( 6 / 9 ) clinical asthma score at four hoursHigher ( 6 / 9 ) clinical asthma score at four hours • • 4 hour sat ≤ 92%4 hour sat ≤ 92% • • 4 hour albuterol more often than q1 hour4 hour albuterol more often than q1 hour • • If none, 82% chance short therapy onlyIf none, 82% chance short therapy only • ≥ • ≥ 3 predictors 92% chance long therapy3 predictors 92% chance long therapy Keogh et al. J Pediatr 2001Keogh et al. J Pediatr 2001