Lasix In Acute Asthma Exacerbation?

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20mg IVP for acute asthma flair with no cardiac history? Attending thought it would work but had no effect except diuresing the patient. Can't find any evidence based practice on it given IV only inhaled.

Any done or seen this in practice?

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Know of it, would never do it.

All your other therapies are likely to be more beneficial, unlikely to have any clinically relevant additive effect from furosemide.
 
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What is the mechanism that works in asthma?
 
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In the past they've looked at inhaled loop diuretics in asthma, believing that the beneficial effects were due to intrinsic anti inflammatory effects of lasix itself and not due to its diuretic activity. Never heard it being given in IV form as an acute tx for an asthma exacerbation.

Maybe he patient presented with undifferentiated respiratory distress and your attending wanted to give a single shot of diuretics in case there was some CHF component? Not saying it's necessarily the right thing to do, but that could have been the line of thinking?
 
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I remember being taught that furosemide can act directly on the lungs as an argument to give if in CHF patients with ESRD (who thus won't have diuresis). So, I get the rationale. However, most of my severe asthmatics are hypOvolemic, so I wouldn't give furosemide.
 
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During asthma exacerbation, all that gasping for air increases insensible losses, making asthma patients volume-down. Lasix sounds counterproductive to me.

perhaps the case was more asthma vs. CHF exacerbation? Even then, IV lasix takes a long time to kick in, so is not really useful for acutely getting fluid off the lungs in the ED.

Just curious about the doc in question, did he/she train in a different time or place? Kind of wondering what the rationale was.
 
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Like dudeMD said, why would undifferentiated respiratory distress call for IV lasix in any case? Is the standard treatment for asthma attacks not continuous albuterol/ipratropium, steroids, and some Mg for the severe cases?
 
Like dudeMD said, why would undifferentiated respiratory distress call for IV lasix in any case? Is the standard treatment for asthma attacks not continuous albuterol/ipratropium, steroids, and some Mg for the severe cases?
While thinking has gone back and forth, the PECARN net has data that Mg decreases admission rate in peds asthma so I routinely give it in patients that I'm going to start an IV on.
 
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Like dudeMD said, why would undifferentiated respiratory distress call for IV lasix in any case? Is the standard treatment for asthma attacks not continuous albuterol/ipratropium, steroids, and some Mg for the severe cases?
Undifferentiated respiratory distress would call for it because one cause of wheezing and respiratory distress is CHF. Sure it takes a while to kick in but so do steroids. That said, I would usually go for bipap first in those cases of undifferentiated distress because of the transient early afterload increase associated with Lasix.
 
We had this discussion before, but whatever. The "while" of Lasix and the "while" of steroids are quite a bit different, in my anecdotal experience. The academic types can say whatever, but all I know is that patients for whom I order Lasix urinate quite readily, and soon enough that, for selected ones, if the Foley isn't placed the most expeditiously, they'll pee the bed. Or is someone going to say with a straight face that the patients just really needed to go, and were just holding it, and it happens, all the time, to be lower osmolality urine, and that it isn't the Lasix?
 
I was under the impression that Lasix doesn't work quick enough to change the rate of admission, whereas numerous studies have shown that giving steroids for asthma in the ED reduces admission, and the onset of action is much quicker than most think. So I would say the two are not equivalents.
 
We had this discussion before, but whatever. The "while" of Lasix and the "while" of steroids are quite a bit different, in my anecdotal experience. The academic types can say whatever, but all I know is that patients for whom I order Lasix urinate quite readily, and soon enough that, for selected ones, if the Foley isn't placed the most expeditiously, they'll pee the bed. Or is someone going to say with a straight face that the patients just really needed to go, and were just holding it, and it happens, all the time, to be lower osmolality urine, and that it isn't the Lasix?
Nobody said Lasic doesn't make people pee quickly. It just doesn't fix their lungs quickly. I'm sorry that your plural of anecdote disagrees.
While thinking has gone back and forth, the PECARN net has data that Mg decreases admission rate in peds asthma so I routinely give it in patients that I'm going to start an IV on.
Mag isn't harmful. However, the older data (including the dribble on thennt) is so skewed it isn't even funny. If Mag truly had an NNT of 2, then it would be the most effective drug on the face of the earth. The 3MG trial showed no benefit in mostly adults. If you want to give it, fine, but give it after the things that have stronger data, like NIV, beta agonists, and steroids.
 
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We had this discussion before, but whatever. The "while" of Lasix and the "while" of steroids are quite a bit different, in my anecdotal experience. The academic types can say whatever, but all I know is that patients for whom I order Lasix urinate quite readily, and soon enough that, for selected ones, if the Foley isn't placed the most expeditiously, they'll pee the bed. Or is someone going to say with a straight face that the patients just really needed to go, and were just holding it, and it happens, all the time, to be lower osmolality urine, and that it isn't the Lasix?

Sure, they pee off some intravascular volume promptly, but the question is whether the compensatory shift of fluid from lungs back to intravascular space is fast/reliable enough to really be using it routinely in the ED for CHF exacerbation. Considering most CHFers who are "fluid overloaded" are actually fluid-down (they're just third-spacing it all into the lungs), I just don't like messing with their tenuous intravascular volume with lasix.

If their hemodynamics were such that they had no problem compensating by shifting the pulmonary edema back into their vascular space, then they wouldn't be having the problem in the first place. In other words, that compensatory shift of fluid from lungs to vasculature that we're trying to achieve with lasix is precisely what wasn't working to begin with. That's why I prefer the nitro strategy for CHF exacerbation.
 
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Sure, they pee off some intravascular volume promptly, but the question is whether the compensatory shift of fluid from lungs back to intravascular space is fast/reliable enough to really be using it routinely in the ED for CHF exacerbation. Considering most CHFers who are "fluid overloaded" are actually fluid-down (they're just third-spacing it all into the lungs), I just don't like messing with their tenuous intravascular volume with lasix.

If their hemodynamics were such that they had no problem compensating by shifting the pulmonary edema back into their vascular space, then they wouldn't be having the problem in the first place. In other words, that compensatory shift of fluid from lungs to vasculature that we're trying to achieve with lasix is precisely what wasn't working to begin with. That's why I prefer the nitro strategy for CHF exacerbation.
None of this is news. The question of fluid overload or not is the one that differentiates the nitro whole hog vs the Lasix (along with the nitro).
 
Mag isn't harmful. However, the older data (including the dribble on thennt) is so skewed it isn't even funny. If Mag truly had an NNT of 2, then it would be the most effective drug on the face of the earth. The 3MG trial showed no benefit in mostly adults. If you want to give it, fine, but give it after the things that have stronger data, like NIV, beta agonists, and steroids.

I guess you can construct a scenario where giving Mg has a downside, but it involves some pretty convoluted circumstances. Nobody's saying don't BiPap (that's a bit of a strawman) them if they're struggling, but even in the 3MG trial the OR just barely avoided significance for IV Mg (p-value 0.084). Does it raise people from the dead? No. Does it prevent hospital admissions? In children, yes. In adults, possibly. If you're going to put in an IV, why wouldn't you give Mg?
 
I guess you can construct a scenario where giving Mg has a downside, but it involves some pretty convoluted circumstances. Nobody's saying don't BiPap (that's a bit of a strawman) them if they're struggling, but even in the 3MG trial the OR just barely avoided significance for IV Mg (p-value 0.084). Does it raise people from the dead? No. Does it prevent hospital admissions? In children, yes. In adults, possibly. If you're going to put in an IV, why wouldn't you give Mg?

Agreed. There are few worse respiratory issues than having to tube a bad asthmatic. These people do not do well on the vent. If there is something I can give to my subset of real bad exacerbations that has virtually no downside and may help them, I will all day long.

As for the lasix, the way I see it, it has more potential to harm than the mag does, with even less evidence of efficacy
 
Agreed. There are few worse respiratory issues than having to tube a bad asthmatic. These people do not do well on the vent. If there is something I can give to my subset of real bad exacerbations that has virtually no downside and may help them, I will all day long.

As for the lasix, the way I see it, it has more potential to harm than the mag does, with even less evidence of efficacy
When was the last time you had to tube an asthmatic? I honestly can't remember, it's been so long. NIV works so well that I haven't had to in years. And the rare person that I think is getting close, ketamine is on my mind before magnesium, or at least concominantly. LIfe isn't like a board exam, and you can order stuff at the same time. However, unless there's more than one nurse, they often can't give more than one drug at the same time, and if the mag infusion is going, they'll be damned sure that they're going to look it up to see if the other things you're ordering are "compatible" with it.
 
Never. What's the indication? In the undifferentiated SOB/resp distress, if one is concerned about CHF, they aren't perfusing the beans anyway. CHF is NOT a state of lasix deficiency (though out cardiology colleagues may disagree.) I agree with others, non-invasive positive pressure ventilation is going to save their butts most times, and I always give Mag in resp distress. Continuous nebs, steroids, mag, NPPV. Ketamine to chill out. Sometimes I'll give them nebulized epi w the kitchen sink treatment plan. But if you can't avoid it, if they get tired/worse, tube them.
 
When was the last time you had to tube an asthmatic? I honestly can't remember, it's been so long. NIV works so well that I haven't had to in years. And the rare person that I think is getting close, ketamine is on my mind before magnesium, or at least concominantly. LIfe isn't like a board exam, and you can order stuff at the same time. However, unless there's more than one nurse, they often can't give more than one drug at the same time, and if the mag infusion is going, they'll be damned sure that they're going to look it up to see if the other things you're ordering are "compatible" with it.

I haven't personally had to tube an asthmatic in a while, but I've dealt with the after effects in the ICU of intubated asthmatics.

And we aren't allowed to use ketamine in our ED for adult patients. They're trying to change that but it's the policy now. Only time I've used ketamine is for Peds procedural sedation, don't have much experience with it otherwise.
 
And we aren't allowed to use ketamine in our ED for adult patients. They're trying to change that but it's the policy now.
That's about anesthesia trying to protect turf.
 
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Good snark. Surprised I missed that, initially.
Well, he works in snark like the old masters did in oil. Quite candidly, if he ever posted anything that was wholeheartedly nice, I would think someone hacked his account (and I've met him - I bought him dinner years ago when he was an intern).
 
Well, he works in snark like the old masters did in oil. Quite candidly, if he ever posted anything that was wholeheartedly nice, I would think someone hacked his account (and I've met him - I bought him dinner years ago when he was an intern).
Sure did. And I appreciate it today as much as I did then. That remark was a continuation of a prior thread where we discussed the lasix =/= best practice CHF treatment today, no matter how much it used to be.
And it certainly isn't appropriate for asthma.
 
Sure did. And I appreciate it today as much as I did then. That remark was a continuation of a prior thread where we discussed the lasix =/= best practice CHF treatment today, no matter how much it used to be.
And it certainly isn't appropriate for asthma.
Well, it changed my practice - and the staff did look at me with concern when I told them to turn the nitro on wide open and hold the Lasix. Damn Newton and the whole inertia thing!
 
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