[Medical treatment of respiratory emergencies]

Of the four treatments that can be used to treat respiratory insufficiency due to laryngitis, two, nebulized adrenaline and O2 therapy, are undoubtedly effective. The inhalation of water vapour appears to be increasingly useless and may be also harmful. The use of steroids is still under debate. In recent literature, however, the utility of steroids seems to be confirmed, especially if administered per Os, and even at a relatively low single oral dose (1-2 mg/kg of prednisone). According to the official organs (see Red Book) and according to the Evidence Based Medicine (see Cochrane Library) the treatment of bronchiolitis should be limited to an eventual support therapy, i.e. O2 therapy and rehydration. However, the approach adopted by North American Hospitals and European specialists in infectious diseases is in contrast and consists in the use of beta 2 agonists and steroids in 90-100% and 40-80% of patients, respectively. This contrast could be due to a deficiency in the researches of the Evidenced Based Medicine which is obliged to retrieve studies done over 10-15 years in order to obtain a sufficient number of data for a statistically valid investigation. These studies unfortunately are not updated with regard to the dose of individual drugs and the immediate association of drugs. In particular, with regard to nebulized beta 2 agonists, the absence of a positive effect could be due to an excessively low dose in relation to the age of the patient. According to the most recent knowledge, in fact, reduced doses are no longer required for babies in consideration of age and weight. In reality an equal and even higher dose than that used in adults would be best. The other reason for a lack of response could be the absence of the association of a steroid with a beta 2 agonists at the right moment. The lack of timing in associating these two drugs could also account for the absent response to the steroid. On the basis of these considerations it would be a mistake to give up the use of beta 2 agonists and steroids. Considering also the severity and frequency of a disease as bronchiolitis. To follow the "fashion" of the Evidence Based Medicine. Recently, magnesium sulphate, ketamine and the association elium-O2 have been suggested as marginal and not revolutionary medical interventions for the treatment of asthma. Among bronchodilators, the subordinate role of anticholinergics (for ex. ipratropium bromide), and of adrenaline has been defined with respect to beta 2 agonists, in particular salbutamol. The optimisation of the administration by nebulizers of the latter has been fundamental as it has a key role in the treatment of acute severe asthma. In detail, traditional nebulizers tend to be substituted by Metered Dose Inhaler + spacer with a ratio in the dose of 5/1. The venous route is used only in very severe cases and is used late and in intensive care although a single initial intravenous administration could determine a more rapid reduction of bronchoconstriction and reduce the number of nebulized bronchodilatators that can become extremely frequent in most severe cases. For steroids, instead, the only safe therapeutic route is by PO, i.v., i.m.: nebulized steroids although used with a definitely higher dose than that used for chronic asthma, can be used only in the milder forms.