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Pediatr Emerg Care. <http://www.ncbi.nlm.nih.gov/pubmed/23364383#> 2013
Feb;29(2):191-6. doi: 10.1097/PEC.0b013e3182809b48.
Evaluation of a high-dose continuous albuterol protocol for treatment of
pediatric asthma in the emergency department.
Krebs SE
<http://www.ncbi.nlm.nih.gov/pubmed/?term=Krebs%20SE%5BAuthor%5D&cauthor=true&cauthor_uid=23364383>
1, Flood RG
<http://www.ncbi.nlm.nih.gov/pubmed/?term=Flood%20RG%5BAuthor%5D&cauthor=true&cauthor_uid=23364383>
, Peter JR
<http://www.ncbi.nlm.nih.gov/pubmed/?term=Peter%20JR%5BAuthor%5D&cauthor=true&cauthor_uid=23364383>
, Gerard JM
<http://www.ncbi.nlm.nih.gov/pubmed/?term=Gerard%20JM%5BAuthor%5D&cauthor=true&cauthor_uid=23364383>
.

Abstract
OBJECTIVES:

This study aimed to assess the safety and efficacy of a high-dose
continuous nebulized albuterol (CNA) protocol for treatment of asthma in
the pediatric emergency department (ED). A secondary objective included a
cost-benefit analysis of protocol use.
METHODS:

In this retrospective chart review, we compared cohorts of patients treated
in our ED for acute asthma exacerbation before and after implementation of
a CNA protocol. Patients between the ages of 2 and 21 years seen between
March 1 and May 31, 2008 (preprotocol, n = 393), and March 1 to May 31,
2009 (postprotocol, n = 373), were included. Safety data included
medication-related adverse effects as well as serum potassium and glucose
levels. Efficacy data included ED length of stay, disposition, return
visits, time to first albuterol treatment, and corticosteroid
administration. Cost analysis included the cost of medications and
respiratory therapy time.
RESULTS:

Postprotocol patients more often received CNA (57.9% vs 25.2%, P < 0.01).
No significant adverse effects, including tachyarrhythmia and symptomatic
hypokalemia, were found in either group. Serum potassium levels were higher
in the postprotocol group (3.9 mEq/L [n = 34] vs 3.5 mEq/L [n = 28], P <
0.01). Emergency department stay was longer in the postprotocol group
(217.8 minutes vs 187.2 minutes, P < 0.01). Emergency department
disposition was similar in both groups. The mean cost per patient was
higher in the postprotocol group ($327.21 vs $277.95, P < 0.01).
CONCLUSIONS:

We found the CNA protocol to be safe. Superior efficacy to a traditional
treatment approach was not demonstrated. The mean cost of treatment was
higher in the postprotocol group. Further prospective studies should be
conducted to confirm the findings of this retrospective, observational
study.


Doses administrated based on weight and Clinical Asthma Score *>* 3:

1) Weight < 20 kg: Albuterol 10 mg/hour

2) Weight > 20 kg: Albuterol 20 mg/hour


Our Clinical Practice Guideline can be found on our Webpage:

http://www.cardinalglennon.com/Documents/emergency-medicine/asthma-clinical-practice-guide.pdf


Bob Flood

Cardinal Glennon Children's Medical Center

St. Louis, MO

On Wed, Feb 11, 2015 at 12:22 PM, Jay Fisher <[log in to unmask]> wrote:

> Another high dose albuterol reference from the Mesozoic period-
>
> Up to 50 mg/hr in 1 yo bronchiolitics - ahh what fond memories - rewriting
> aminophylline orders at 3 am with wet hair from the croup mist tent in the
> next crib.
>
> Katz R et al. Pediatrics 1993;92:666-669
>
>
> Jay Fisher MD
> Medical Director
> Pediatric Emergency Services
> Children's Hospital of NV
>
> On Tue, Feb 10, 2015 at 10:57 AM, Linzer, Jeffrey F <[log in to unmask]>
> wrote:
>
> > Jim -
> >
> >
> >
> > In our system we are currently using 7.5 mg of albuterol in continuous
> > breathing treatments for patients <15 kg and 15 mg ≥15 kg.
> >
> >
> >
> > Back in the day when I was doing my fellowships we used undiluted (0.5%)
> > continuous albuterol where doses ranging between 60-90 mg/hr were used.
> An
> > abstract of our experience was published in Ped Emergency Care (Linzer J,
> > Vance C, Letorneau M. 1996. Safety of continuously nebulized undiluted
> > albuterol in children with severe acute asthma. Pediatr Emerg Care
> > 12:328.). The average heart rate on presentation was 150.9 bpm and at
> > disposition from the ED 162.3 bpm. No clinically significant dysrhythmias
> > were noted.
> >
> >
> >
> > Unlike adults, there is a direct dose-response relationship of albuterol
> > in kids which is one of the reasons we use relatively higher does than in
> > adults. Additionally, younger, healthier hearts can tolerated high heart
> > rates longer than older adults (this author included). We generally found
> > that the heart rate would peak and then decrease as the patient's
> > bronchoconstriction started to reverse.
> >
> >
> >
> > Overall, the current albuterol dosing in children even with the
> associated
> > side effects of nausea, vomiting and tachycardia, is more effective and
> > relatively safer then the old "3 epis and a Sus-Phrine" or IV
> aminophylline
> > or isoproterenol.
> >
> >
> >
> > Jeff
> >
> >
> >
> > Jeffrey Linzer Sr., MD, FAAP, FACEP
> > Professor of Pediatrics and Emergency Medicine
> > Emory University School of Medicine
> > Associate Medical Director for Compliance
> > EPG/Division of Pediatric Emergency Medicine
> > Lead Physician, ICD-10-CM Transition Core Leadership Team
> > Children's Healthcare of Atlanta
> >
> > [cid:[log in to unmask]]
> >
> >
> >
> >
> >
> >
> >
> >
> > -----Original Message-----
> > From: Pediatric Emergency Medicine Discussion List [mailto:
> > [log in to unmask]] On Behalf Of Marty Herman
> > Sent: Tuesday, February 10, 2015 10:45 AM
> > To: [log in to unmask]
> > Subject: Re: continuous albuterol in young asthmatics
> >
> >
> >
> > JIm,
> >
> > I have seen it but then again can't recall if the kid was < 2.
> >
> > Might try Xopenex for that kid in the future..
> >
> > Of course in a young child with a healthy heart, not sure 200-210 is a
> > problem for a few hours, as long as they are well oxygenated...
> >
> >
> >
> >
> >
> > I remember when I started my career, We would start aminophylline drips
> on
> > kids that failed to break with 3 sub cut epi shots.  if that didn't work
> > and the kid was in severe distress, asthmatics were put on an
> isoproterenol
> > drip. we would start an A line to monitor their heart rates and titrate
> the
> > Isoproterenol to keep the HR at 200.  Never witnessed or heard of any
> > reactions to that protocol.
> >
> > when that fell out of favor we began using tertbutaline drips for the
> > worst cases.
> >
> > of course epi was also an alternative for infusions..
> >
> > with all these powerful agonist, only witnessed hr > 200 a few times..
> >
> >
> >
> > so I am thinking in your case it was just a rare event..
> >
> >
> >
> > Marty
> >
> > Martin Herman, M.D.
> >
> >
> >
> > Pediatric Emergency Medicine
> >
> > Sacred Heart Children's Hospital
> >
> >
> >
> > Email: [log in to unmask]<mailto:[log in to unmask]>
> >
> >
> >
> > > Date: Mon, 9 Feb 2015 18:16:24 -0500
> >
> > > From: [log in to unmask]<mailto:[log in to unmask]>
> >
> > > Subject: continuous albuterol in young asthmatics
> >
> > > To: [log in to unmask]<mailto:[log in to unmask]>
> >
> > >
> >
> > > We are initiating continuous albuterol for asthmatics in the ED (10
> > mg/hr for kids < 15kg, 15 mg/hr for > 15kg).  I have had 2 kids, each
> about
> > 18-20 months old, develop heart rates to 210-220/min with this treatment.
> > Neither had SVT, both were early in the process of continuous (not
> > prolonged therapy).  Has anyone had this experience with younger
> > asthmatics?  Not sure if this is just bad luck or something we should
> > include in protocol (continuous for 2 years and older only).  Would
> > appreciate any input.
> >
> > > Thanks
> >
> > > Jim Naprawa
> >
> > > Nationwide Children's Hospital
> >
> > > Columbus, OH
> >
> >
> >
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