‘Out-the-Door’ v. ‘Kitchen-Sink’ Asthma Management

​Are you one of those clinicians who frequently finds himself frustrated with asthma patients who improve to a point but not enough to discharge home? Even though this has to be a common problem, no one seems to talk or write much about it. I was feeling deeply frustrated about these patients, and it led me to serious clinical introspection. Why does everyone write about the crashing asthma patient, but hardly anyone addresses the problematic patient with improving but recalcitrant bronchospasm?Most articles typically cover every available therapeutic option, including the proverbial “kitchen sink” for managing severe asthma emergencies. Kitchen-sink recommendations generally include continuous albuterol nebulization, intravenous magnesium sulfate, intramuscular epinephrine or terbutaline, noninvasive (NIV) positive pressure ventilation, helium-oxygen administration, and ultimately intubation and ventilation using ketamine. It is time, however, to give “out-the-door” asthma management a little respect and attention.Typically, emergency department asthma protocols will include repeated albuterol treatments with at least two of those treatments combined with nebulized ipratropium bromide. Corticosteroids are also administered orally or intravenously. When these initial interventions fail, most practitioners continue to treat the bronchospasm with additional doses of albuterol and ultimately continuous nebulization of the β2 agonist.This is where logic seems to fade. ...
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