BPD diuretic and steroid questions

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Not sure if this is the best place to ask this question. I have some confusion about these two situations in BPD, and i'd appreciate hearing others' perspectives or references of where to learn more.

1. Why give diuretics and sodium supplements together? After diurects are started, naturally sometimes the sodium level drops enough to the point of concern. The reflex of some neos is to start sodium supplements. This has never made sense to me. I prefer to wean, stop or change the diuretics or keep trending the sodium level. Is there biologic rationale for giving diuretics in combination with sodium supplements? This situation comes up in many other areas of medicine, so i'd imagine there's some literature on this specific question?

2. Why give inhaled steroids in combination with systemic steroids? The patient is currently on systemic steroids due to the severity of their BPD and current state. In addition to the systemic steroids, the neonatologist starts inhaled steroids. Why? This also does not make sense to me. Is there biologic rationale for why inhaled steroids may have benefit on top of systemic steroids. The evidence for inhaled steroids is suspect at best already.

I would appreciate insight. Both of these situations have come up a lot my experience.

 

[DO2015CA]

Not sure if this is the best place to ask this question. I have some confusion about these two situations in BPD, and i'd appreciate hearing others' perspectives or references of where to learn more.

1. Why give diuretics and sodium supplements together? After diurects are started, naturally sometimes the sodium level drops enough to the point of concern. The reflex of some neos is to start sodium supplements. This has never made sense to me. I prefer to wean, stop or change the diuretics or keep trending the sodium level. Is there biologic rationale for giving diuretics in combination with sodium supplements? This situation comes up in many other areas of medicine, so i'd imagine there's some literature on this specific question?

2. Why give inhaled steroids in combination with systemic steroids? The patient is currently on systemic steroids due to the severity of their BPD and current state. In addition to the systemic steroids, the neonatologist starts inhaled steroids. Why? This also does not make sense to me. Is there biologic rationale for why inhaled steroids may have benefit on top of systemic steroids. The evidence for inhaled steroids is suspect at best already.

I would appreciate insight. Both of these situations have come up a lot my experience.

1) your approach would be fine but those BPDers have immature kidneys too so for my PBD patients on diuretics (lasix>diuril) more often than not they need the supplement. But if you want to wait and trend sodium then start, fine. I would say not to wean diuretics because dry lungs are happy lungs. Especially if you are trying to not trach. If no pHTN then your goal would be to room to RA which diuretics will help you.

2) there is no physiologic reason. Like you allude plain Jane BPD does not show benefits with addition of ICS. BPD does lead to increased airway hyperreactivity. I’ll recommend to trial bronchodilation for episodes of respiratory distress and if there is response then there would be argument for ICS. When there is systemic steroids on board, ICS is a drop in the bucket. Now I could see an argument if it’s hydrocortisone for adrenal insufficiency as it’s pretty low dosing for physiology and I’m not sure how much airway anti inflammation you gain but that’s a grey zone.

 

[oldbearprofessor]

The sodium is a bit tricky. At least in our business, for severe BPD, the overall effect of a loop diuretic seems to be important enough to allow for the consequences of some sodium replacement. Of note is that sodium is often the wrong cation to replace! Although the serum K+ might not drop markedly in some cases, potassium depletion is generally worse with the loop diuretics than sodium depletion and keep in mind you are replacing not just the cation but also the chloride being lost.

The only rationale I can see in the second circumstance would be if you were planning on stopping the systemic steroids. But, I generally don't use inhaled steroids as they don't do much if anything.

 

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Thanks for the responses!