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Santa Fe Update

Santa Fe Update. How does an MDI compare with a neb machine for acute asthma. Background. Nebs used to deliver albuterol in EDs and clinics; often prescribed for home use Neb medicine perceived by docs and families as more effective Advantages of MDI: delivery is quicker; portability; cost.

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Santa Fe Update

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  1. Santa Fe Update How does an MDI compare with a neb machine for acute asthma

  2. Background • Nebs used to deliver albuterol in EDs and clinics; often prescribed for home use • Neb medicine perceived by docs and families as more effective • Advantages of MDI: delivery is quicker; portability; cost

  3. Several studies have established that equivalent doses are equally effective (neb vs MDI) in acute setting • Young infants and children with moderate severity attacks • MDI/spacer actually preferred by most parents

  4. Recommendations • Consider using in the clinic/ED • Dosing 8 puffs from MDI equivalent to 2.5 mg unit dose of neb • Teach age-appropriate spacer technique • Must recruit respiratory therapy support to implement

  5. Is there an alternative to orapred? • Short burst of systemic steriods is beneficial in acute asthma attack • Oral and parenteral routes are equivalent • Oral prednisone poorly tolerated and 5 day duration (10 doses) variably accepted

  6. Evidence • Decadron has a longer half life than prednisone (36-72 hours) • IV form (4 mg/ml) can be safely administered orally and is well tolerated (tasteless!!!) • Two doses of dex 24 hours apart better tolerated and equally effective as 5 days of prednisone in RCT (Qureshi, 2001)

  7. Consider • Oral decadron (use IV form) 0.6 mg/kg in clinic and repeated at home for 2 total doses • Can use for croup as well (2 nd dose may not be necessary) • Must enlist cooperation of pharmacy for institution!!!

  8. Stepping on toes?? • Assess the diathesis of the patient during and acute visit • Rule of 2s: more than 2 daytime symptoms per week; 2 nighttime symptoms per month; 2 ER visits or hospitalizations per year • Suggests persistent inflammation • Start inhaled steroids!!!

  9. Bronchiolitis revisited • Mainstay of therapy: fluids and oxygen • Other Rx include bronchodilators (albuterol), epi (racemic), and steroids (systemic and inhaled)

  10. Evidence • Beta 2 agonists have not been shown to reduce clinical symptoms • Two meta-analyses (Kellner, Flores): no effect on hosp, RR or oxygenation; minimal effect on clinical scores • Further studies were called for • Oral albuterol is of no benefit (Patel, 2003)

  11. Primatene mist is OTC • 6 recent RCTs of racemic favor use of epi in acute bronchiolitis • Small but statistically significant improvement in scores and oxygenation • One Outpt study showed decreased hosp rate (Menon, 1995) • Wainright (2003) found no diff in LOS racemic vs placebo

  12. No, no not again…. • Meta-analysis of RCTs (Garrison, 2000) suggests earlier clinical improvement and shorter hospital stays • Exclusion of pt with previous wheezing the delta (DOS/LOS) was not significant • Small but well designed RCT dex vs placebo: benefit in resp status and hosp rate (recurrent wheezers excluded)

  13. Did you say something?(directed to the AAP) • Oral hydration recommended for mild to moderate dehydration with 558.9 • Survey says: practicioners prefer IV fix • Evidence: RCTs have established effectiveness of oral rehydration • Recent RCT of IV vs oral (50cc per kg over 3 hours) in 96 children 3-36 months showed equivalent outcomes (clinical improvement, admission rate)

  14. Furthermore • NG hydration was superior to IV in terms of cost-effectiveness and complication rate • Routine labs did not alter Rx or help with diagnosis • Smaller study showed decreased time in ER with oral route

  15. Recommendations • Minimize blood draws/IVs • Consider PO or NG hydration • NG better in younger infants • Diet: restore age appropriate diet ASAP to restore nutrition, gut motility and healing • Breast is always acceptable; formula does not need to be diluted (once vomiting stops); avoid FS juices (osmotic load)

  16. The tap is cloudy…. • Pneumococcus is currently the major cause of meningitis in children more than 1 year of life (already in decline due to prevnar!!) • Pathology indicates damage due to inflammation rather than bacterial invasion • Severity correlates to outcome

  17. From hemophilus and beyond.. • H flu disease experience showed convincing reduction in long-term sequelae • 1997 meta-analysis concluded that steroids offered benefit to children with both hemophilus and pneumococcus • RCT in 301 adults improved survival and outcome with dex (deGans, 2002)

  18. Timing is critical • The tap is cloudy… • The patient is greater than 6 weeks • Initiate steroids ASAP; preferably BEFORE ABX • 0.15 mg per kg per dose of decadron IV • Give q 6 for 4 days • Rocephin and Vancomycin

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