Asthma exac

[WheezyBaby]

What is y'all's approach to managing patients with acute asthma exacerbation who, after their initial nebs and steroid dose, remain subjectively (to the patient) quite dyspneic / unimproved but objectively are reasonably stable (may have persistent significant wheezing, but reasonable air exchange, at most mildly tachypneic, talking full sentences, no accessory mm use, no supplemental oxygen, etc)? Put them on continuous for a bit, go ahead and try to space them?

And just in general, when if ever are y'all using peak flows?

Just trying to get some insight on practice variation outside my institution, thanks!

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[Brigade4Radiant]

I do 1omg albuterol and 1 mg ipratropium then repeat another 10mg after an hur or two most get better. I used peak flows like once when I was a resident. I don't now.

 

[thegenius]

What is y'all's approach to managing patients with acute asthma exacerbation who, after their initial nebs and steroid dose, remain subjectively (to the patient) quite dyspneic / unimproved but objectively are reasonably stable (may have persistent significant wheezing, but reasonable air exchange, at most mildly tachypneic, talking full sentences, no accessory mm use, no supplemental oxygen, etc)? Put them on continuous for a bit, go ahead and try to space them?

And just in general, when if ever are y'all using peak flows?

Just trying to get some insight on practice variation outside my institution, thanks!

Well, provided this is truly an asthma exacerbation and not something else causing the dyspnea.

I (almost) never give a single 2.5 mg albuterol neb in the ED. If you are sick enough to come into the ED with asthma, then I give a continuous neb for 1 hour, specifically 10 mg albuterol and 0.5 mg ipratropium. It follows that I (almost) always prescribe steroids as well. Most of the time prednisone, occasionally dexamethasone if I feel they are going to be non-compliant or homeless or just need a little steroids.

If not better, I repeat the continuous neb again.

Moderate, especially severe asthma exacerbations, in particular those that you plan on admitting, benefit from IV magnesium sulfate 2g. Just remember that it must be infused over 20 minutes and not 1-2 hours. There are a few special occasions where infusing mag quickly is a must: status asthmaticus, (pre)eclampsia, torsades come to mind.

Lots of asthma exacerbations get better and don't have to be admitted. I have been known to keep people in the ER for 8-10 hours to break their cycle. I especially do this with kids. They will get 3, sometimes 4 rounds of continuous nebs.

I rarely use Peak Flow, but not because it doesn't provide valuable information. RT must do that test and they don't carry them around, and by the time they get it the pt has been waiting for 2+ hours...

 

[Rendar5]

What is y'all's approach to managing patients with acute asthma exacerbation who, after their initial nebs and steroid dose, remain subjectively (to the patient) quite dyspneic / unimproved but objectively are reasonably stable (may have persistent significant wheezing, but reasonable air exchange, at most mildly tachypneic, talking full sentences, no accessory mm use, no supplemental oxygen, etc)? Put them on continuous for a bit, go ahead and try to space them?

And just in general, when if ever are y'all using peak flows?

Just trying to get some insight on practice variation outside my institution, thanks!

Admit. done. (provided they're not malingering and no alternative diagnosis)

 

[gro2001]

What is y'all's approach to managing patients with acute asthma exacerbation who, after their initial nebs and steroid dose, remain subjectively (to the patient) quite dyspneic / unimproved but objectively are reasonably stable (may have persistent significant wheezing, but reasonable air exchange, at most mildly tachypneic, talking full sentences, no accessory mm use, no supplemental oxygen, etc)? Put them on continuous for a bit, go ahead and try to space them?

And just in general, when if ever are y'all using peak flows?

Just trying to get some insight on practice variation outside my institution, thanks!

The situation you describe is exactly the one where a peak flow would be useful. Your clinical exam is just not that good at stratifying the severity of asthma compared to a peak flow. Actually, the patient's own perception is also better than your clinical exam (but not as good as a peak flow). So I would never blow off a patient's sense that they are not improving. Doing a peak flow and seeing what percentage of predicted it is, as well as if there is a trend towards improvement or not would help you figure out what's going on. This may reveal one of three situations:

1) They are actually improving according to the peak flow, but don't feel better. Give them another round of nebs, get their paperwork ready to go (prescriptions, etc), let them know their results are good and that you are planning to discharge them after this round of nebs. Most people will go with the flow.

2) They are not improving, but not getting worse. Escalate. Another round of nebs (3 back-to-back or continous), IV mag (don't tell me it doesn't work), consider alternative diagnosis. Get a CXR. I would continue this for quite a bit before admitting defeat. Just make sure to keep the albuterol coming. They have an acute albuterol deficiency.

3) They are getting worse. Escalate as in 2. Consider IM epi. Look for alternative causes. Admit. Keep a very close eye on them for possibility of requiring ICU admission.

 

[deleted109597]

The data for 1 hour continuous over 3 single nebs is pretty strong. They either need an hour, or they can go home on their MDI.
Steroids early. BiPAP early if needed. Magnesium data is all over the map, but it's not harmful, so give it if you feel like it.

Also, strong work on the username/thread synergy.

 

[thegenius]

The data for 1 hour continuous over 3 single nebs is pretty strong. They either need an hour, or they can go home on their MDI.
Steroids early. BiPAP early if needed. Magnesium data is all over the map, but it's not harmful, so give it if you feel like it.

Also, strong work on the username/thread synergy.

I remembered the magnesium NNT for severe asthma exacerbations was something like 8
but then I went to thennt PERIOD com and it's even better.

(I tried putting in the link! But I can't put in links yet...)

Note that it's for severe attacks. For instance, if I'm giving magnesium for asthma exacerbation, i always charge critical care time. I probably admit 1/3 of those patients too.

 

[Brigade4Radiant]

The data for 1 hour continuous over 3 single nebs is pretty strong. They either need an hour, or they can go home on their MDI.
Steroids early. BiPAP early if needed. Magnesium data is all over the map, but it's not harmful, so give it if you feel like it.

Also, strong work on the username/thread synergy.

Can you link these studies?

 

[OneTwoThreeFour]

Magnesium Sulfate for Asthma Attack – TheNNT

actually looks like the NNT for severe asthma is 3!

 

[deleted109597]

Magnesium Sulfate for Asthma Attack – TheNNT

actually looks like the NNT for severe asthma is 3!

That was from the older papers (written by Ashley in 2010 and hasn't been updated). 3Mg study says it's ineffective. The 3Mg trial: a randomised controlled trial of intravenous or nebulised magnesium sulphate versus placebo in adults with acute severe asthma. - PubMed - NCBI

Cochrane agrees, at least for kids. Intravenous magnesium sulfate for treating children with acute asthma in the emergency department. - PubMed - NCBI

 

[deleted109597]

Can you link these studies?

https://www.annemergmed.com/article/S0196-0644(05)80411-1/abstract
Continuous versus intermittent beta-agonists in the treatment of acute asthma. - PubMed - NCBI

 

[thegenius]

That was from the older papers (written by Ashley in 2010 and hasn't been updated). 3Mg study says it's ineffective. The 3Mg trial: a randomised controlled trial of intravenous or nebulised magnesium sulphate versus placebo in adults with acute severe asthma. - PubMed - NCBI

Cochrane agrees, at least for kids. Intravenous magnesium sulfate for treating children with acute asthma in the emergency department. - PubMed - NCBI

Moreover, the NNT of 3 is for a subgroup analysis of "severe asthmatics". The meta analysis had, overall, significant heterogeneity meaning the studies were all over the place.

Meaning we need better, narrower cohort studies.

 

[deleted109597]

Moreover, the NNT of 3 is for a subgroup analysis of "severe asthmatics". The meta analysis had, overall, significant heterogeneity meaning the studies were all over the place.

Meaning we need better, narrower cohort studies.

Grasping at straws. 3Mg was the trial designed specifically to look for this. Severe exacerbations by definition. >1000 people. No effect. Smaller studies try to show effect, but they have ridiculous fragility indices.

 

[Zebra Hunter]

Grasping at straws. 3Mg was the trial designed specifically to look for this. Severe exacerbations by definition. >1000 people. No effect. Smaller studies try to show effect, but they have ridiculous fragility indices.

Also, I can't think of many interventions that have an NNT of 3. That is WAY too good to be true. It reminds me of the ridiculous IV Mg studies for magnesium in acute MIs which found a 50% reduction in mortality (that's RRR).

 

[deleted109597]

Also, I can't think of many interventions that have an NNT of 3. That is WAY too good to be true. It reminds me of the ridiculous IV Mg studies for magnesium in acute MIs which found a 50% reduction in mortality (that's RRR).

Yep. No medicine has an NNT of 3.

 

[scummie]

If they are legit asthma exacerbation, 1 hour long (10-15 mg), repeat with another after reassessment. Will also throw in the duoneb too. Hit em up with some steroids and magnesium at the get go. If they are still pretty tachypneic, really wheezy or just not turning the corner, I'll admit after the second hour long. Have also had some good things about epi for what it's worth.

 

[gro2001]

Grasping at straws. 3Mg was the trial designed specifically to look for this. Severe exacerbations by definition. >1000 people. No effect. Smaller studies try to show effect, but they have ridiculous fragility indices.

I am too emotionally attached to magnesium to stop giving it in severe asthma exacerbations just because of some "evidence".

 

[deleted109597]

I am too emotionally attached to magnesium to stop giving it in severe asthma exacerbations just because of some "evidence".

I mean, you're not an emergency doctor if you haven't seen a condition and thought "a little mag won't hurt".

 

[turkeyjerky]

Back to the OP, in this case I would reassure the patient that it sounds like they're getting better and then order a 2nd hr long neb. I generally prep the patient that they're going home after. Sometimes I will have the RT get a peak flow if either the patient or myself needs extra reassurance, but it typically doesn't change management. Generally, COPDers get to request admission for subjective dyspnea, asthmatics don't.

I typically give mag if the patient is sick enough that I'm getting an IV (which is obtained for access in case of decompensation, Not for IV steroids)

 

[Zebra Hunter]

Lol, and then you have Swami (of EM:RAP, FOAMed fame) recommending giving up to 8mg!!! for asthmatics at a conference today. Where do these guys get this stuff? Makes you question a lot of the stuff they say when they are spouting off nonsense like this. Entirely the reason why I do my own literature review of important papers.

 

[deleted109597]

And I just spoke with her!
Tweets can sometimes leave out important details such as supporting articles. Hopefully Swami or Tarlan will speak up. Weingart certainly doesn't use Mag anymore.

 

[Apollyon]

What, titrate to loss of DTRs?

 

[VA Hopeful Dr]

What, titrate to loss of DTRs?

When I was in med schools that's pretty much what the OBs did

 

[WilcoWorld]

Lol, and then you have Swami (of EM:RAP, FOAMed fame) recommending giving up to 8mg!!! for asthmatics at a conference today. Where do these guys get this stuff? Makes you question a lot of the stuff they say when they are spouting off nonsense like this. Entirely the reason why I do my own literature review of important papers.

Yeah, Swami is too strident for my tastes.

 

[Psai]

Lol, and then you have Swami (of EM:RAP, FOAMed fame) recommending giving up to 8mg!!! for asthmatics at a conference today. Where do these guys get this stuff? Makes you question a lot of the stuff they say when they are spouting off nonsense like this. Entirely the reason why I do my own literature review of important papers.

I mean you can easily give 4-6 in eclampsia no problem.

 

[thegenius]

Yep. No medicine has an NNT of 3.

There is!

Lidocaine for Reducing Pain on Injection of IV Propofol – TheNNT

NNT 3

LOL

 

[thegenius]

Lol, and then you have Swami (of EM:RAP, FOAMed fame) recommending giving up to 8mg!!! for asthmatics at a conference today. Where do these guys get this stuff? Makes you question a lot of the stuff they say when they are spouting off nonsense like this. Entirely the reason why I do my own literature review of important papers.

Yea sometimes I think they say that stuff just so they can be considered to be at the leading edge of emergency medicine. They are just saying stuff just to say it.

There is not one article of someone studying giving 2mg x4 over like 1 hour in asthma.

 

[WildcatS11]

Well, provided this is truly an asthma exacerbation and not something else causing the dyspnea.

I (almost) never give a single 2.5 mg albuterol neb in the ED. If you are sick enough to come into the ED with asthma, then I give a continuous neb for 1 hour, specifically 10 mg albuterol and 0.5 mg ipratropium. It follows that I (almost) always prescribe steroids as well. Most of the time prednisone, occasionally dexamethasone if I feel they are going to be non-compliant or homeless or just need a little steroids.

If not better, I repeat the continuous neb again.

Moderate, especially severe asthma exacerbations, in particular those that you plan on admitting, benefit from IV magnesium sulfate 2g. Just remember that it must be infused over 20 minutes and not 1-2 hours. There are a few special occasions where infusing mag quickly is a must: status asthmaticus, (pre)eclampsia, torsades come to mind.

Lots of asthma exacerbations get better and don't have to be admitted. I have been known to keep people in the ER for 8-10 hours to break their cycle. I especially do this with kids. They will get 3, sometimes 4 rounds of continuous nebs.

I rarely use Peak Flow, but not because it doesn't provide valuable information. RT must do that test and they don't carry them around, and by the time they get it the pt has been waiting for 2+ hours...

I agree with a lot of this, but I can’t imagine giving 3 hours of continuous neb’s and discharging someone. Especially a kid. I mean they have to have some rock solid parents, and follow up like later that day. Or else in my mind, they didn’t need the 3 hours of continuous.

Where I trained, the floor would refuse to take a patient like that if they had required that much albuterol - it was automatic ICU (we didn’t have step down).

Am I missing something here?

 

[WheezyBaby]

Appreciate all of the insight!

The data for 1 hour continuous over 3 single nebs is pretty strong. They either need an hour, or they can go home on their MDI.
Steroids early. BiPAP early if needed. Magnesium data is all over the map, but it's not harmful, so give it if you feel like it.

Also, strong work on the username/thread synergy.

Making this thread was my initial intention when I made the account, but I didn't want that to be transparent so I made a couple years of fluff posts

 

[Apollyon]

Appreciate all of the insight!



Making this thread was my initial intention when I made the account, but I didn't want that to be transparent so I made a couple years of fluff posts

580+ posts to lead up to this? Now THAT is a strong long game.

 

[gro2001]

I agree with a lot of this, but I can’t imagine giving 3 hours of continuous neb’s and discharging someone. Especially a kid. I mean they have to have some rock solid parents, and follow up like later that day. Or else in my mind, they didn’t need the 3 hours of continuous.

Where I trained, the floor would refuse to take a patient like that if they had required that much albuterol - it was automatic ICU (we didn’t have step down).

Am I missing something here?

You are not. Kids I would actually try to space out. Hit em hard at first and then see how far I can space out the repeat albuterols. If I can only space them to Q1 hour they get admitted to ICU, Q2 they get admitted to floor, Q4 they go home (assuming no high risk criteria, like congenital heart/lung issues, very young baby, ex-premie, etc). I'll usually go at this for up to 6 hours or so before I give up and admit.

 

[Groove]

What is y'all's approach to managing patients with acute asthma exacerbation who, after their initial nebs and steroid dose, remain subjectively (to the patient) quite dyspneic / unimproved but objectively are reasonably stable (may have persistent significant wheezing, but reasonable air exchange, at most mildly tachypneic, talking full sentences, no accessory mm use, no supplemental oxygen, etc)? Put them on continuous for a bit, go ahead and try to space them?

And just in general, when if ever are y'all using peak flows?

Just trying to get some insight on practice variation outside my institution, thanks!

Man, some of you guys hang onto your asthma exacerbations a lot longer than I do.

My gen approach:

10mg continuous albuterol + atrovent + steroids +/- mag (severe, voodoo), +/- BIPAP (severe and/or fatigued) and for the most part I can dispo after the first hour when I reassess. If they have continued requirements, it's pretty easy deciding tele vs ICU. If they are significantly improved and close to baseline with no high risk features then home.

I can't remember the last wheezer I kept in the ED for a few hours gnashing my teeth over spacing. At most, I might have an ICU hold that I managed to get spaced and stable for tele or vice versa. I also can't remember the last solitary neb I ordered. Most get 10mg over an hour right out of the gate.

 

[thegenius]

I agree with a lot of this, but I can’t imagine giving 3 hours of continuous neb’s and discharging someone. Especially a kid. I mean they have to have some rock solid parents, and follow up like later that day. Or else in my mind, they didn’t need the 3 hours of continuous.

Where I trained, the floor would refuse to take a patient like that if they had required that much albuterol - it was automatic ICU (we didn’t have step down).

Am I missing something here?

Well...I don't do 3 hours back to back to back. It would be 1 hr continuous nebs x3 over 8-10 hrs. Need time for the steroids to kick in. And I wouldn't do this for all kids.
1) I can't admit peds to my hospital, I have to transfer them. That in-of-itself takes 2-4 hours. By the time ambulance comes, the kids are better.
2) I wouldn't do this if the parents weren't knowledgeable, supportive, etc.
3) This was done where I trained at CHONY (Columbia - NYC) regularly that's just how I think.
4) Sometimes the kids have been transferred previously, and I ask them how long they were admitted....and they say "oh overnight. They released us the next morning. Please don't transfer us unless you absolutely have to." LOL

 

[KGflyboy]

How many of you give kids who go home po decadron and discharge without a prescription for outpatient steroids? Peds EM people I work with do this all the time. Some of the general ED people seem to be more likely to use something like prednisolone in the ED and prescribe enough to continue taking it for a few days.

 

[deleted859535]

How many of you give kids who go home po decadron and discharge without a prescription for outpatient steroids? Peds EM people I work with do this all the time. Some of the general ED people seem to be more likely to use something like prednisolone in the ED and prescribe enough to continue taking it for a few days.

I remember reading a noninferiority trial between the two a couple years or so ago.

In young adults and kids just old enough to take medications without a fuss, I tend to still do prednisolone. Dex goes to my young kiddos and those who may have compliance/follow-up issues.

 

[deleted109597]

How many of you give kids who go home po decadron and discharge without a prescription for outpatient steroids? Peds EM people I work with do this all the time. Some of the general ED people seem to be more likely to use something like prednisolone in the ED and prescribe enough to continue taking it for a few days.

Every time. Seems like you work with dinosaurs.

 

[thegenius]

I remember reading a noninferiority trial between the two a couple years or so ago.

In young adults and kids just old enough to take medications without a fuss, I tend to still do prednisolone. Dex goes to my young kiddos and those who may have compliance/follow-up issues.

Yes I remember as well, decadron is slightly worse...like we are talking just a few percent difference. And specifically I recall that study was only in peds. Not tested for adults (if we care about EBM, and I do). That being said I have not yet made it a habit discharging with decadron. I use prednisolone 1 mg/kg for four days. I use decadron about 10% of the time.

 

[deleted109597]

Yes I remember as well, decadron is slightly worse...like we are talking just a few percent difference. And specifically I recall that study was only in peds. Not tested for adults (if we care about EBM, and I do). That being said I have not yet made it a habit discharging with decadron. I use prednisolone 1 mg/kg for four days. I use decadron about 10% of the time.

There was an adult study that did not reach non-inferiority, but patient outcomes were similar. So I still do it. A Randomized Controlled Noninferiority Trial of Single Dose of Oral Dexamethasone Versus 5 Days of Oral Prednisone in Acute Adult Asthma. - PubMed - NCBI

 

[Groove]

How many of you give kids who go home po decadron and discharge without a prescription for outpatient steroids? Peds EM people I work with do this all the time. Some of the general ED people seem to be more likely to use something like prednisolone in the ED and prescribe enough to continue taking it for a few days.

Yes, I give Orapred Rx to the kiddos. Identical Rx as @thegenius.

 

[deleted109597]

Honestly, Orapred tastes terrible. And compliance is pretty poor in the littles, especially when it tastes bad. Also, the way we dose steroids is literally "well, let's just come up with a number." When they reduced decadron from 0.6mg/kg to 0.15mg/kg there was no difference. For a 75% reduction in meds.

 

[thegenius]

Honestly, Orapred tastes terrible. And compliance is pretty poor in the littles, especially when it tastes bad. Also, the way we dose steroids is literally "well, let's just come up with a number." When they reduced decadron from 0.6mg/kg to 0.15mg/kg there was no difference. For a 75% reduction in meds.

Dr. McNinja apparently knows his asthma literature!

 

[Groove]

Honestly, Orapred tastes terrible. And compliance is pretty poor in the littles, especially when it tastes bad. Also, the way we dose steroids is literally "well, let's just come up with a number." When they reduced decadron from 0.6mg/kg to 0.15mg/kg there was no difference. For a 75% reduction in meds.

Where do you get that Orapred tastes terrible? Are you sure you don't mean Prelone? All the taste studies I read show that Orapred typically tastes better. Anecdotally, I can't think of anytime I've had parents of know asthmatics who are familiar with Orapred tell me that the kid had issues taking it due to the taste.

Taste comparison of corticosteroid suspensions. - PubMed - NCBI

Selecting an Oral Prednisolone Liquid for Children

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2003.tb01358.x

 

[deleted109597]

Maybe the pharmacies here are just terrible at substituting. Maybe parents don't explain it well. But I never have people say they like it. And I bet if you ask your repeat offenders if they have any left from the last visit, they probably all do. I prefer the 100% compliance of an oral dose of decadron in the ED. I still explain to the parents why that's as effective as going home, but they don't have to force the kid to take medicine and nobody has ever pushed back asking for prednisolone for home. YMMV.

 

[deleted547339]

Why is this even a question? Admit, move on.