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Asthma Therapies – What Really Works?

Mel Herbert, MD and David Newman, MD
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Patients with asthma will present to us for their acute exacerbations. Listen to Dave Newman as he distills down what works? What doesn’t? And help your patient avoid hospital admission and attain discharge home

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Kaylin O. -

what is the thought on covering these patients with antibiotics secondary to significant steroid use? I find myself doing the exact same treatment...duoneb, IM steroid, home on a medrol dose pack, albuterol HFA plus or minus nebulized albuterol depending circumstance...however, I still almost always cover these patients with a zpack as well

Mike W., MD -

Weinstock: I would recommend against this. If there is a consideration of a bacterial process such as pneumonia (fever, positive CXR) then by all means, but the typical asthma exacerbation is a combination of bronchoconstriction and inflammation so my thought is that ATB would be more harmful than beneficial. And besides, you have national guidelines on your side for that 1 in a million case!

Mizuho M., DO -

Agree with Mike on this. Although a viral URI might often be a trigger for reactive airway exacerbation, there are many triggers for asthma. Rarely would you ever have a bacterial component to a typical asthma exacerbation; thus antibiotics are not warranted in most cases. Thanks for your comments!

mark w., md -

how about using spacers with MDIs??

Mizuho M., DO -

He didn't mention spacers, but YES current literature supports the use of spacers with MDI's.

Daniel G. -

The Audio described using 30mg during a continous(1hr) albuterol/atrovent treatment. Is that 30mg of Albuterol only or 30mg of both or a combination?

Daniel G. -

forgot to ask, is it same dose adult vs peds?

Mizuho M., DO -

George- thanks for your questions.

Regarding question 1) Dave Newman in the segment refers to a STUDY that reviewed INTERMITTENT vs. CONTINUOUS albuterol and their conclusions were that "continuous nebulisers produce a modest reduction in admissions compared to intermittent beta-agonist therapy. This finding was especially pronounced in severe acute asthma. Continuous nebuliser therapy may be more effective than intermittent nebulisers for delivering beta-agonist drugs to relieve airway spasm in selected asthma populations. " Please see reference listed in the segment for more details. Camargo CA, et al. Continuous versus intermittent beta- agonists for acute asthma. Cochrane Database Syst Rev. 2003;(4):CD001115. [PMID: 14583926]
The conclusion you can take home from this, is that in patients with SEVERE exacerbation, Continuous nebulizers are beneficial over staggered. In most of the studies they reviewed, they used anywhere from 20-30 mg/hour of albuterol mixed with 0.5mg ipatropium mixed together. However this study doesn't discuss the optimal dosing of patients, they review various dosing that was used, and confirmed that continuous would be better than staggered.

Clinically, to answer your question, I think most of us start with 10-15mg/hour Albuterol + 0.5mg ipatriopium and titrate up as clinically warranted. However depending on how the patient appears clinically... if they are in extremis, I would probably start higher and be able to justify starting at 20mg + but this particular detail is yet to be evidence based.

2)Regarding pediatric dosing...NO you cannot use adult dosing. All medications for pediatrics NEED to be weight based (Kg)
For Inhaled Albuterol for Pediatrics with acute bronchospasm < 12 year old patients = 0.15 mg/kh NEB q 20 mins x 3, and if you are moving up to continuous it would be 0.5mg/kg/hr (with of course a MAX of adult dosing 10-15mg/hr). **Please refer to a pharmacotherapy reference source (i.e.: Epocrates) for confirmation of pediatric doses, as there are different concentrations % of albuterol available.

Hope this helps. ~Mizuho

Ian L., Dr -

When is it useful to push nebulisation with 6L oxygen .
Clearly if there is co-existing COPD you ought go intranasal oxygen 1-2 l a minute after getting Po2 to 92 at least aiming to keep the Po2 at 92 .

Mike W., MD -

Agreed. Especially with COPD, there is potential harm from getting the sat up to 100%. Shooting for 92% is a good goal.

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Syncope, Asthma & Otitis Gone Wild Full episode audio for MD edition 215:32 min - 251 MB - M4AUrgent Care RAP 2015 April Summary 1,010 KB - PDF

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