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Santa Fe Update

This article reviews the effectiveness of metered-dose inhalers (MDI) versus nebulizers in treating acute asthma attacks, especially in young children. While nebulizers have traditionally been favored, studies show that MDIs, particularly with spacers, offer comparable efficacy and additional advantages such as faster delivery, lower cost, and better portability. Recommendations include considering MDIs in clinical settings, educating families on proper spacer techniques, and exploring alternatives to oral steroids, like dexamethasone, that may be better tolerated.

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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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