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Notes from the Community – Bronchiolitis – Part 2

Rob Orman, MD and Andrew Sloas, DO RDMS FAAEM
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Nurses Edition Commentary

Mel Herbert, MD MBBS FAAEM, Lisa Chavez, RN, and Kathy Garvin, RN
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EM:RAP 2014 August - Summary 1 MB - PDF

It’s never too early to get ready for bronchiolitis season!

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Jennifer M. -

Dr. Sloas,
This question is on peds asthma, - sorry its not on bronchiolitis.
Last month, in the asthma section, it was recommended to give continuous nebulizer treatments over intermittent treatments. In children with moderate to severe asthma, is it safe to give three continuous duonebs?
Or do you need to calculate the total of three albuterol treatments if given internmittanty over an hour, place in a Nebulizer and administer it continuously over one hour? If that is the case, do you do the same for atrovent since in severe asthma you want to use the beta agonist and anti-cholinergic? Thanks for your help.
Thanks.

Rob O -

Hi Jennifer. Here is the response from Andy Sloas....

One should view lungs with acute asthma as grades of fire (2 alarm, 3 alarm, etc). Do the firefighters ask how much water to put on the fire? No, they pound that fire with water until it’s gone. Albuterol will not make the head, heart or lungs explode so think of yourself as a firefighter and just coat those pulmones with albuterol until the fire is out. As far as the anticholinergics…there’s a new article out that from Cochrane that says it doesn’t hurt, but also doesn’t work in hospitalized patients: Vézina. Inhaled anticholinergics and short-acting beta2-agonists versus short-acting beta2-agonists alone for children with acute asthma in hospital. Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD010283 but there’s weak evidence that it helps break asthma in mild-mod ED patients to the point that you may be more likely to discharge them from the ER. When things don’t hurt, but may help I usually continue to use them. If you were to give a ton of anticholinergics then you may cause some anticholinergic toxicity in theory (red as beat, hot as Hades, mad as a hatter, etc), but at the worst the kid probably gets a little agitated. What do I do? Start continuous albuterol (beta), add 3 doses of the anticholinergics (making the duo neb), then I continue the albuterol (beta) by itself and do not go back to the anticholinergics in those that do not respond and need more treatment. You’re not going to do any harm and it may help.

Kevin M., MD -

LOL at the Dr. Walker impression. Having trained ay Grady, I would know that particular voice anywhere! Good talk on Bronchiolitis and very timely as well.

Louis V., MD -

Woooaaaa... Have you guys seen the latest recommendations for bronchiolitis?

http://pediatrics.aappublications.org/content/134/5/e1474.full.pdf?sid=b7ff2872-9e3a-4c6d-b8a8-39d92890231d

i feel like if i have been living a lie..... is this real? Am I in the twilight zone? No oxigen, no steroids, no Racemic Epi.??!! Really?? What does a nylon else think of this? !

Jack G. -

Yeah ... what do people think about the new AAP guidelines??

Jack G. -

Like Rob I work at high altitude (9100 ft). Everyone goes home on oxygen.

Bronchiolitis ... Oxygen. HAPE ... oxygen. Sprained ankle ... oxygen.

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Episode 155 Full episode audio for MD edition 275:00 min - 131 MB - M4AEM:RAP 2014 août Résumé en Francais Français 65:33 min - 60 MB - MP3EM:RAP 2014 August Aussie Edition Australian 73:57 min - 102 MB - MP3EM:RAP 2014 August Canadian Edition Canadian 30:52 min - 43 MB - MP3EM:RAP 2014 Augusto Resumen Español Español 83:27 min - 77 MB - MP3EM:RAP 2014 August MP3 359 MB - ZIPEM:RAP 2014 August - Summary 1 MB - PDFEM:RAP 2014 August Board Review Questions 379 KB - PDFEM:RAP 2014 August Board Review Answers 421 KB - PDF

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