The Asthma Cocktail
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- Опубликовано: 1 июн 2017
- This video intends to open the discussion about proven but little used alternative treatments for asthma exacerbations that are not improving sufficiently with current and more standard therapies. This video intends to remind us that Beta2 agonist receptors can fatigue causing them to be less effective. Steroids tend to reduce this "fatigue" and mixing up treatment with other options for Beta2 agonists that very well may have slightly different receptors should be considered. This video was previously uploaded, but was taken down in order to meet peer review requests to include a disclaimer.
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Hi Dr Mellick,
I was just curious about the choice of ibuprofen. My understanding was that NSAIDs carry a risk of actually exacerbating asthma.
The mechanism behind it being that the decreased prostaglandin production causes a relative increase in leukotriene production.
I'm looking at this from my anaesthetics point of view, where most of our patients are well and not in the middle of an attack. Is this different when a patient is in the middle of an attack?
Regards,
Cam.
That is a good question but I think the available evidence doesn't show that to be an issue. We do know that arachadonic acid is a significant inflammatory player in asthma and ibuprofen targets it. I think the anti-inflammatory benefit of ibuprofen outweighs any risks. And, it doesn't appear to be a problem in the day to day management of asthma patients. See the links below.
www.ncbi.nlm.nih.gov/pubmed/27532828
www.ncbi.nlm.nih.gov/pubmed/11826230
www.pharmgkb.org/pathway/PA166121942
Thanks for your response!
What a great kid. Raises his hand to speak. Good manners kiddo. Your mom is proud. You can tell as she smiles when you raise your hand.
Absolutely agree!
It’s nice to see you professor.
I am accustomed to hearing your voice already.
Thank you very much for the great work you are doing for doctors, health care workers and humanity in general .👍🏾👍🏾👍🏾
Thank you for the kind words.
Status asthmaticus is no joke. Scary stuff for such a little boy.
That's incredible! Not only did his breathing significantly improve, but he looked 100% better in general after the treatment. Great job Dr. Mellick!
Thanks!
Poor baby. I know how it feels to have asthma. It pains me when children are sick or hurt.
Dr. Mellick, another excellent case presentation. Thank you.
I can't thank you enough for these great videos! I'm so grateful to have found your channel!
What a lovely boy.
Good parenting and lots of love shows through kids like this.
Im an aspiring Dr trying to help the poor and underserved communities and really appreciate these videos . 🙏
I swear I'm just going to watch one more video...
THANKS DOCTOR MELLICK UPLOAD MORE VIDEOS LIKE THAT ITS WONDERFUL
Thank you, we will definitely try.
Yes please, I'm a previous psych nurse, new in the ED.. your videos are very informative:)
awesome. Thanks for breaking it down Dr. Mellick!
So glad he's okay!
I used this today, but also with magnesium. The kid turned around and I saved them a transfer to Boston which the patient and family were happy about. Thank you!
Excellent, excellent! Glad to hear someone else is having success with these "alternative" approaches.
make a more interview-like videos in the end! You are amazing doc!
Will do. Thanks!
Bless his heart. My grandson has asthma and it's tiring and scary for them! I wish there was a cure .
I have used it as a last ditch effort in adults before intubation and it really does work
Good work Docs...
I have a question , why and what causes the Inflammation of the airways ?
what is the cause ?
Is it idiopathic truly or the allergens the main factor ?
or is the Oxidative Stress the main cause ?
Dr. Mellick please do more paediatric cases! Great video!
Thanks! I do as many pediatric videos as I can.
I'll be 61 this coming March, I was born with what is considered light asthma, half my life no one believed me about it, about 12 years ago I had to take a week off adult high school to recover from rectal surgery to remove a fistula, I didn't know what the outcome of being intubated would be, having the intubation tube removed caused me to have the worst asthma attack of my entire life, you know it's really bad when you're clawing at your throat trying to get air into your lungs, I always say at the moment you know whether you want to live or die, I thought I was going to die, my best advice is to make double sure you tell the nurses and doctors your medical history and all medications you're on so they can take action a whole lot faster, I remember one nurse saying to the other nurse "she has a history of asthma" they moved real fast and had a hard time keeping my hands away from my throat.
Please take my advice for your own sake.
good to see you sir.
Thank you!
asthma is shitty, kid is such a nice little dude bless him
I know how it feels to have asthma and not be able to breath. I have adult onset asthma it started when I was 15. Until I was prescribed Adviar I had a monthly ER visit. It is scary as hell!
My wife was prescribed terbutaline for preterm labor.
Thanks.
Your are welcome!
#LIFESAVERS!!!
hi doc! what do you usually give as home meds? im worried about exacerbations yet i understand unnecessary iv meds and hospital stays.. do you start on seretide + albuterol prn + montelukast? thank you so much!!!
I don't start patients on leukotriene receptor antagonists, but occasionally will do inhaled steroids in addition to increasing the frequency of beta agonists and a burst of oral steroids if I didn't use dexamethasone. Thanks for the question.
Why not prednisone? That works wonders for my son.
What about using BiPap to help with the asthma exacerbation?
Dr. Mellick, did the patient in this video just receive the nebulized steroid? Any pred?
Bruce Tomaszewski He also received oral dexamethasone at 0.6 mg per kilogram with a maximum of 16 mg. There is some evidence that using both oral and nebulized has a better outcome.
Dr. Mellick< I am 66 years old and asthmatic since a child. My asthma was dormant for at least 16 years and started acting up since I was 55. My Pulmonologist has tried all kinds of meds not it doesn't seem to control the Still short of breath and wheezing. Can I tell my doctor about the Racemic epineferin to see if it would work for me. I was hospitalized last year Nov. 6 and I'm afraid I'm headed in the same direction. I remember when Alupent worked for me years ago. Marilyn Ocampo-Scott, Florida.
Terbutaline maybe over racemic epinephrine, but yes. He can give a try.
Thank you so much for responding. My doctor does not want to try the racemic epinephrine on me so I'm a bit upset. I am running out of options for myself. Plus my immune system has gone down considerably.
Could you also consider SQ epi without the racemic epi or does the nebulized epi provide for more of a prolonged effect.
SQ epi definitely works and you are giving about 0.3 mg maximum. It also causes the child pain. However, with racemic epinephrine you are giving (by nebulization granted where you lose some of it) 11.25 mg of epinephrine. Actually at first I started giving the epinephrine intramuscular (because we know that is the best) until my nurses started pushing back and complaining about causing the child pain. Knowing that I needed to keep my nurses happy, I came up with this option which in the end may be much better.
I understand it is always better to try and keep the child comfortable
Hi Dr.Mellik
Does all NSAIDS have benefits or just ibuprofen?
I don't know. And, again, this is mostly theoretical based on the role of ibuprofen with the inflammatory factors. It clearly hits important inflammatory factors in asthma and isn't much risk of harm in children without aspirin allergies. Consequently, I felt it was appropriate to include in my asthma cocktail which I start when nothing else seems to be working.
Poor sweet baby
Hey Larry and everybody else,
I am writing an assignment on the topic of using alternative methods to treat asthma that is unresponsive to the traditional asthma treatment pathway. To me the pharmacology makes perfect sense, but I was wondering if there are any studies that support the use of alternative asthma pathways?
Regards,
Greg
Here are a few...
References
1. Edmonds ML, Milan SJ, Camargo Jr CA, Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD002308.
2. Volovitz B. Inhaled budesonide in the management of acute worsenings and exacerbations of asthma: a review of the evidence. Respir Med. 2007 Apr;101(4):685-95. Review.
3. Wiebe K, Rowe BH. Nebulized racemic epinephrine used in the treatment of severe asthmatic exacerbation: a case report and literature review. CJEM. 2007 Jul;9(4):304-8.
4. Plint AC, Osmond MH, Klassen TP. The efficacy of nebulized racemic epinephrine in children with acute asthma: a randomized, double-blind trial. Acad Emerg Med. 2000 Oct;7(10):1097-103.
5. Rodrigo GJ, Nannini LJ. Comparison between nebulized adrenaline and beta2 agonists for the treatment of acute asthma. A meta-analysis of randomized trials. Am J Emerg Med. 2006 Mar;24(2):217-22.
6. Adoun M, Frat JP, Doré P, Rouffineau J, Godet C, Robert R. Comparison of nebulized epinephrine and terbutaline in patients with acute severe asthma: a controlled trial. J Crit Care. 2004 Jun;19(2):99-102.
7. Kjellman B, Tollig H, Wettrell G. Inhalation of racemic epinephrine in children with asthma. Dose-response relation and comparison with salbutamol. Allergy. 1980 Oct;35(7):605-10.
8. Barisione G, Baroffio M, Crimi E, Brusasco V. Beta-Adrenergic Agonists. Pharmaceuticals (Basel). 2010 Mar 30;3(4):1016-1044. Review.
9. emedicine.medscape.com/article/137501-overview#a1
10. Calderón MA, Linneberg A, Kleine-Tebbe J, De Blay F, Hernandez Fernandez de Rojas D, Virchow JC, Demoly P. Respiratory allergy caused by house dust mites: What do we really know? J Allergy Clin Immunol. 2015 Jul;136(1):38-48. Epub 2014 Nov 22.
11. Gelfand EW. Role of histamine in the pathophysiology of asthma: immunomodulatory and anti-inflammatory activities of H1-receptor antagonists Am J Med. 2002 Dec 16;113 Suppl 9A:2S-7S.
12. Wilson AM. Are antihistamines useful in managing asthma? Curr Opin Allergy Clin Immunol. 2002 Feb;2(1):53-9.
13. Wilson AM. The role of antihistamines in asthma management. Treat Respir Med. 2006;5(3):149-58.
14. Zitt MJ. The role of nonsedating antihistamines in asthma therapy. Allergy Asthma Proc. 2003 Jul-Aug;24(4):239-52.
15. Nelson HS. Prospects for antihistamines in the treatment of asthma. J Allergy Clin Immunol. 2003 Oct;112(4 Suppl):S96-100.
16. Wenzel SE. Arachidonic acid metabolites: mediators of inflammation in asthma. Pharmacotherapy. 1997 Jan-Feb;17(1 Pt 2):3S-12S.
17. Mazaleuskaya Liudmila L, Theken Katherine N, Gong Li, Thorn Caroline F, FitzGerald Garret A, Altman Russ B, Klein Teri E . "PharmGKB summary: ibuprofen pathways" Pharmacogenetics and genomics (2014).
18. Kauffman RE, Lieh-Lai M. Ibuprofen and increased morbidity in children with asthma: fact or fiction? Paediatr Drugs. 2004;6(5):267-72.
19. Kanabar D, Dale S, Rawat M. A review of ibuprofen and acetaminophen use in febrile children and the occurrence of asthma-related symptoms. Clin Ther. 2007 Dec;29(12):2716-23.
20. Lesko SM, Louik C, Vezina RM, Mitchell AA. Asthma morbidity after the short-term use of ibuprofen in children. Pediatrics. 2002 Feb;109(2):E20.
21. Nomani S, Cockcroft DW, Davis BE. Allergen inhalation challenge, refractoriness and the effects of ibuprofen. Allergy Asthma Clin Immunol. 2016 May 24;12:24.
Thank you Larry for this large list. I really appreciate it and for your reply.
hi dr mellick, i read that budesonide is not for acute attack, but for regular and maintenance use, as it will not work or relive acute attack
Actually, there are several excellent reviews including a Cochrane review that says it works in the acute setting.
proffesor can i ask you 2 questions in dka, and i will appreciate your response very much
Dr. Mellick off topic but if You had an ER Patient come in with Pain and they requested IV/IM Tordol and then a few Anaprox DS to go home would You consider in this case that The Patient was Drug Seeking?
Ketorolac is a non-opioid anti inflammatory and naproxen can be readily purchased anywhere in the US without a prescription.
As someone who was recently diagnosed with asthma, this is pretty interesting.. Does he have a more serious type of asthma ?
Glad this was helpful! Hopefully, he will grow out of this to some extent. He does apparently have fairly frequent episodes.
My 7 year old has been diagnosed with asthma for 4 years now. Luckily she never gets this bad. She just coughs A LOT. She's on quite a few meds for her asthma. 2 maintenance inhalers and a rescue inhaler when she is having a hard time
Andrea Becker I've more than likely had Asthma for awhile but finally after 6 years they did a breathing capacity test, I was at 90 when people my age/height are at 300. Got other tests done and was finally diagnosed with acute asthma, I hope your kid starts to grow out of the worst phase!
I remember one time I had asthma attack and my mom didn't believe me. Bye the time I got to clinic my heart rate was 220 .
I remember one time I had asthma attack and my mom didn't believe me. Bye the time I got to clinic my heart rate was 220 .
Mother mentioned that this child is one albuterol daily. Is he on a controller med, too? Seems to me that something like Qvar would prevent an episode like this from happening.
I think he was, but I don't remember the specifics.
He's on Advair everyday twice a day and then his albuterol is as needed
He's on Advair everyday twice a day and then his albuterol is as needed
Nice nintendo-esque music
What about the use of mag sulfate.
Definitely evidence for that option. We use it on our pathway for the non-responders and for the sicker patients. However, unless you nebulize it (and the evidence isn't great for that opition) you have to start an intravenous line. My personal goal is to avoid intravenous lines on children as long as I can. So, I will often try the cocktail first before going to magnesium sulfate. More often than not I don't need the magnesium sulfate.
Larry Mellick thanks doc I love the idea of holding back on intravenous line an increase of anxiety will definitely increase the respiratory distress.
I use mag sulfate and a low dose of ketamine (0.1 mg.kg), in addition to budesonide and racemic epi. Works great. Then, if you end up having to intubate the kid (this boy was close) I always stay with ketamine for the RSI.
isn't this an old upload?
Yes, it is, but see my note. Bascially, the video peer review team wanted me to insert the disclaimer at the beginning of the video. I had taken it down in order to revise the video and it took a few weeks to get it back up.
Dr Mellick What Was The Outcome On This Patient ?
Hi Dr Mellick,
As a Respiratory therapy student I found this video very interesting and educating. Definitely something to keep in mind as I continue my training and when I eventually practice as an RRT. Also do you know if the patient receives different brands of Albuterol at home? Ex Ventolin one month then Proair the next? I heard that changing up the brands reduces desensitization
I feel so bad for this guy I can practically feel him breathing on me...
man that is one cute fuckin' kid. well done doc
Poor baby
According to the Washington Manual of Medical Therapeutics: "During an exacerbation, systemic corticosteroids speed the resolution of exacerbations of asthma and should be administered promptly to all patients." Not using steroids as in this case puts him at great risk of rebounding few hours later and perhaps serious consequences.
They were administered both orally (dexamethasone) and by nebulization (budesonide).
Inhaled steroids or budesonide are not rescue medicines. I discussed this case today with a Stanford top medical school graduate. In status asthmatics, oral prednisone is superior to oral dexamethasone because of quicker onset of action-that's, it has a shorter half life. Ibuprofen has no role in bronchial asthma. Diphenhydramine should be used with caution because it sedating effect may endanger an asthmatic who is trying to stay awake to breathe. Diphenhydramine can have a paradox (act as an upper) reaction in children but most get sedated by it.
Thanks for your comments. There are plenty of papers out there supporting inhaled budesonide in the acute setting including a Cochrane review. Oral dexamethasone last much longer and frequently one dose is all that is needed. I agree with the cautions on the diphenhydramine and in the tiring child this should be withheld until conditions stabilize. The role of ibuprofen is more theoretical and is currently the least completely defined of the medications proposed, but the literature out there supports that it not harmful and may be helpful. Of course, aspirin sensitive patient should not be given ibuprofen. Thankfully, those are much less common in children. When the smoke clears, we hope to do several staged studies of this cocktail of medications. Don't worry, I receive the same skeptical but appropriate questioning back at my shop. However, my patient's are getting better and going home or to the floor instead of the ICU. Hopefully soon I can have stronger evidence to support these observations, but that's how research projects get started. Thanks again.
www.ncbi.nlm.nih.gov/pubmed/27532828
www.ncbi.nlm.nih.gov/pubmed/11826230
Luis Lomeli What does Stanford have to do with anything?
Luis. Interesting, and common comments to attempts at creative solutions to problems, but no citations and no data to support your statements. As someone who has worked at multiple "high powered" academic institutions, the dogma often followed is not always evidence based, but rather authority based. And the latter has been shown to be of historic value, but often wrong. Dr. Mellick publicly called this a topic open for discussion and requested dialogue and alternative evidence.