My main reason for sticking with the low/standard (2 puffs q4h prn) dosing
is that I
regularly see patients in the ED with near fatal (and occ. fatal) asthma
that they've unsuccessfully tried to manage at home
relying solely on erratic doses of beta agonist (without any other meds).
By telling them that they must come in if they need more than the standard
dose, I can help them determine if they need inhaled steroids, mast-cell
inhibitors, treatment of a sinusitis or GERD
or whatever else before they get in serious trouble. In my very rural area,
it is not uncommon to see locals/farmers and their children with such such
advanced inflammatory reaction that it's very hard to bring them around in
the ED -- and they're on nothing other than Ventolyn.
But your point is well-taken, neb treatments probably supply more than the
standard MDI dose which is one part of the reason that I am reticent to
prescribe them in anyone other than the youngest of children - and I make
sure these patients are watched closely.
Perhaps your patients have fewer problems? Maybe they are more compliant on
From: virgil <[log in to unmask]>
To: Multiple recipients of list PED-EM-L <[log in to unmask]>
Date: Thursday, September 09, 1999 10:22 PM
Subject: Re: MDI
>Out of curiousity why do you stress not to use the same dose at home?
>After all I regularly send patients home with nebulizers - 1 SVN q 4-6
>hours during acute attack, why not 6-8 puffs with a spacer q 4-6 hours?
>At 11:24 AM 9/8/99 -0400, Jeanne Lenzer wrote:
>>My recall is that approx. 8 puffs of Ventolyn delivers a dose comparable
>>one alb. neb tx - I use MDIs
>>as first line tx in the ED preferably for a variety of reasons:
>> 1. I can whether the patient is actually able to deliver the
>>to him or herself correctly; (a number of "treatment failures" are
>>delivery failures) - actually the most recent of which was a case in which
>>the patient had mistakenly inserted a steroid inhaler in his beta agonist
>>box and was using that for emergencies!) Another cause for failure was
>>mentioned by an asthmatic physician in some journal noting that the end of
>>the cannister was not as potent (apparently the accelerant is left at the
>> 2. The extra expense and time it take for the neb tx are simply
>>unnecessary in many instances
>> 3. I assure that the patient actually has a fresh MDI in hand to go
>>home - (I don't save the cannister).
>>When I have a patient take a few puffs - I usually just watch their
>>after 2-4 puffs initially and add on as many more
>>puffs as needed - I always caution them that they should never do this at
>>home - that they are in the hospital in a controlled environment where we
>>can deal with any side-effects or reactions - otherwise they might be too
>>tempted to self-tx in the same manner. I know that this issue alone
>>is something that puts off other providers but I still prefer it. I only
>>use the nebulizer when the patient is in such distress that they clearly
>>not going to be able to suck in any real volume. Results have been
>>uniformly excellent - esp. as I can just slide from MDI to neb tx as
>>Our spacers are disposable (re the peak flow meters) but since I'm
>>dispensing the MDI itself its not an issue.
>>From: jay pershad <[log in to unmask]>
>>To: Multiple recipients of list PED-EM-L <[log in to unmask]>
>>Date: Wednesday, September 08, 1999 8:16 AM
>>>In light of all the evidence confirming the successful use of MDI's for
>>>to moderate acute asthma exacerbations, I was wondering if anybody is
>>>them as a first line mode of Beta Agonist administration (instead of
>>>nebulizations) in cooperative patients???
>>>If so, how many puffs? How often? Are you reusing the canisters for
>>>patients? How is the re-use of spacers handled w.r.t sterilization etc?
>>>Thanks for your time & input.
>>>Jay Pershad, MD
>>>For more information, send mail to [log in to unmask] with the
>>message: info PED-EM-L
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>message: info PED-EM-L
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message: info PED-EM-L
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