Albuterol Use Research Articles

A quality improvement initiative to reduce excess inhaled therapy use in the neonatal intensive care unit.

Inhaled medications are commonly used at our single-center, Level IV neonatal intensive care unit (NICU). We lacked a standardized process for measuring efficacy of these medications to guide optimal duration of use, potentially leading to their overuse. We utilized quality improvement methodology to reduce the length of inhaled hypertonic saline (HTS) course durations and high frequency albuterol use. Interventions included education, data sharing, and implementation of a respiratory therapy assessment tool. The average inhaled HTS course duration decreased from 8.7 to 4.2 days. The percentage of q4 albuterol administrations per total albuterol doses administered monthly decreased from 39 to 20%. Developing a shared mental model between interprofessional providers for the indication and effect of inhaled agents and standardizing assessment of these medications' efficacy can reduce their overuse.

Albuterol off-label use in the management of hyperkalemia and students survey

This study aimed to explore the evidence in the off-label use of albuterol in the acute management of hyperkalemia. It also aims to explore the knowledge and opinion of first-year pharmacy students related to this topic. Based on the literature survey, it shows a lack of awareness among first-year pharmacy students regarding albuterol, hyperkalemia, and the use of albuterol for hyperkalemia. Demographic factors, such as income and years of work experience, were shown to influence students' understanding of the topic. Regarding the survey, a total of forty participants completed an online survey, providing information on demographic factors such as age, gender, residency state, employment status, income, education, and work experience. Results revealed a predominantly female and younger student population, with diverse geographic representation and varied employment and income levels. Most participants selected the wrong answer to questions related to albuterol and hyperkalemia, suggesting potential knowledge gaps in this area. These findings highlight the need for targeted educational interventions to enhance student understanding and clinical decision-making skills in pharmacotherapy-related concepts. Further research could evaluate the effectiveness of such interventions in improving student knowledge and patient care outcomes.

Impact of the COVID-19 Pandemic on Low-Value Testing and Treatment of Bronchiolitis.

Viral testing and treatments such as systemic steroids and inhaled corticosteroids are low-value care for routine bronchiolitis. We sought to determine the impact of the COVID-19 pandemic on low-value care in young children with bronchiolitis. This was a retrospective, cross-sectional study using the Pediatric Health Information Systems database. We included children <2 years seen in a pediatric emergency department for bronchiolitis. We selected a priori 3 study periods: September 2018 to February 2020 (prepandemic), March 2020 to August 2022 (early pandemic), and September 2022 to January 2023 (late pandemic). Low-value care included respiratory syncytial virus testing, chest radiography, albuterol, or corticosteroids and was compared across the 3 time periods. At least 1 element of low-value care was provided in 45%, 47%, and 44% of encounters in the prepandemic, early pandemic, and late pandemic periods, respectively. There was little variation in the use of albuterol and chest radiography across time periods and a slight increase in systemic corticosteroid use from prepandemic to early and late pandemic groups. Viral testing increased from 36% prepandemic to 65% early pandemic and 67% late pandemic, which appeared to be driven by SARS-CoV-2 testing and combination viral testing. There was no clinically significant change in low-value care for bronchiolitis during the pandemic. Because of SARS-CoV-2 testing, however, overall frequency of viral testing increased dramatically over time. This marked increase in overall viral testing should be taken into consideration for future quality improvement efforts.

The Use of Albuterol/Budesonide as Reliever Therapy to Reduce Asthma Exacerbations

Prevention of asthma exacerbations and reduction of systemic corticosteroid burden remain unmet needs in asthma. US asthma guidelines recommend concomitant short-acting β2-agonist (SABA) and inhaled corticosteroid (ICS) as alternative reliever at Step 2. The FDA approved a pressurized metered-dose inhaler containing albuterol and budesonide for as-needed treatment or prevention of bronchoconstriction and to reduce exacerbation risk in patients with asthma aged ≥18 years. This combination is approved for use as a reliever with or without maintenance therapy but it is not indicated for maintenance therapy (or for single maintenance and reliever therapy). Intervening with as-needed SABA–ICS during the window-of-opportunity to reduce inflammation during loss of asthma control can reduce exacerbation risk, by exerting both genomic and nongenomic anti-inflammatory effects. We propose that use of albuterol–budesonide rather than albuterol as reliever to manage episodic symptoms driven by acute bronchoconstriction and airway inflammation can improve outcomes. This combination approach, shown to decrease asthma exacerbations and oral corticosteroid burden in patients with moderate-to-severe asthma, represents a paradigm shift for asthma treatment in the US. Further safety and efficacy studies should provide evidence that this type of reliever should be standard of care.

Impact of a Bronchiolitis Clinical Pathway on Management Decisions by Preferred Language.

Clinical pathways standardize healthcare utilization, but their impact on healthcare equity is poorly understood. This study aims to measure the effect of a bronchiolitis pathway on management decisions by preferred language for care. We included all emergency department encounters for patients aged 1-12 months with bronchiolitis from 1/1/2010 to 10/31/2020. The prepathway period ended 10/31/2011, and the postpathway period was 1/1/2012-10/31/2020. We performed retrospective interrupted time series analyses to assess the impact of the clinical pathway by English versus non-English preferred language on the following outcomes: chest radiography (CXR), albuterol use, 7-day return visit, 72-hour return to admission, antibiotic use, and corticosteroid use. Analyses were adjusted for presence of a complex chronic condition. There were 1485 encounters in the preperiod (77% English, 14% non-English, 8% missing) and 7840 encounters in the postperiod (79% English, 15% non-English, 6% missing). CXR, antibiotic, and albuterol utilization exhibited sustained decreases over the study period. Pathway impact did not differ by preferred language for any outcome except albuterol utilization. The prepost slope effect of albuterol utilization was 10% greater in the non-English versus the English group (p for the difference by language = 0.022). A clinical pathway was associated with improvements in care regardless of preferred language. More extensive studies involving multiple pathways and care settings are needed to assess the impact of clinical pathways on health equity.

Asthmalitis? Diagnostic Variability of Asthma and Bronchiolitis in Children

Bronchiolitis and asthma have similar acute clinical presentations in young children yet have opposing treatment recommendations. We aimed to assess the role of age and other factors in the diagnosis of bronchiolitis and asthma in children <24 months of age. We conducted a retrospective cross-sectional analysis of the Pediatric Health Information System database. We included children aged <2 years diagnosed with bronchiolitis, asthma, wheeze, or bronchospasm in emergency department or hospital encounters from 2017 to 2021. We described variation by age and between institutions. We used mixed-effects models to assess factors associated with a non-bronchiolitis diagnosis in children 12 to 23 months of age. We included 554 158 encounters from 42 hospitals. Bronchiolitis made up 98% of encounters for children <3 months of age, whereas asthma diagnoses increased with age and were included in 44% of encounters at 23 months of age. Diagnosis patterns varied widely between hospitals. In children 12 to 23 months of age, the odds of a non-bronchiolitis diagnosis increased with month of age (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.12-1.13), male sex (OR 1.37, 95% CI 1.35-1.40), non-Hispanic Black race (OR 1.54, 95% CI 1.50-1.58), number of previous encounters (OR 2.73, 95% CI 2.61-2.86, for 3 or more encounters), and previous albuterol use (OR 2.24, 95% CI 2.16-2.32). Non-bronchiolitis diagnoses and the use of inhaled bronchodilators and systemic steroids for acute wheezing respiratory illness increase with month of age in children aged 0 to 23 months. Better definitions of clinical phenotypes of bronchiolitis and asthma would allow for more appropriate treatment in acute care settings, particularly in children 12 to 23 months of age.

Outcomes of a respiratory therapist driven high flow nasal cannula management protocol for pediatric critical asthma patients.

This study aimed to determine if a respiratory therapist (RT)-driven high flow nasal cannula (HFNC) protocol could decrease duration of HFNC use, pediatric intensive care unit (PICU) and hospital length of stay (LOS), and duration of continuous albuterol use in pediatric patients with critical asthma. This was a quality improvement project performed at a quaternary academic PICU. Patients admitted to the PICU between 2 and 18 years of age with a diagnosis of asthma requiring continuous albuterol and HFNC were included. Implementation of an RT-driven HFNC protocol [Plan-Do-Study-Act (PDSA) 1] occurred in October 2017. Additional interventions included weaning continuous albuterol and HFNC simultaneously (PDSA 2; March 2019), adjusting HFNC wean rate (PDSA 3; July 2020), and a HFNC holiday (PDSA 4; October 2021). HFNC duration was the primary outcome. Secondary outcomes included LOS data and continuous albuterol duration. Noninvasive ventilation (NIV), invasive mechanical ventilation (IMV), and 7-day PICU and hospital readmission rates were used as balancing measures. A total of 410 patients were included. Patient demographics and adjunct therapy use did not differ among the groups. After PDSA 2, mean HFNC duration decreased (26.8-18.1 h). Mean PICU LOS decreased (41-31.8 h). Mean hospital LOS also decreased (86.5-68 h). These outcomes remained stable during PDSA 3 and 4. Continuous albuterol duration and NIV use were unchanged, while IMV use decreased. An RT-driven HFNC protocol led to decreased length of HFNC and PICU and hospital LOS for pediatric patients with critical asthma without an increase in adverse events.

Management Practices for Standard-Risk and High-Risk Patients With Bronchiolitis.

Management guidelines for bronchiolitis advocate for supportive care and exclude those with high-risk conditions. We aim to describe and compare the management of standard-risk and high-risk patients with bronchiolitis. This retrospective study examined patients <2 years of age admitted to the general pediatric ward with an International Classification of Diseases, 10th Revision discharge diagnosis code of bronchiolitis or viral syndrome with evidence of lower respiratory tract involvement. Patients were defined as either standard- or high-risk on the basis of previously published criteria. The frequencies of diagnostic and therapeutic interventions were compared. We included 265 patients in this study (122 standard-risk [46.0%], 143 high-risk [54.0%]). Increased bronchodilator use was observed in the standard-risk group (any albuterol dosing, standard-risk 65.6%, high-risk 44.1%, P = .003). Increased steroid use was observed in the standard-risk group (any steroid dosing, standard-risk 19.7%, high-risk 14.7%, P = .018). Multiple logistic regression revealed >3 doses of albuterol, hypertonic saline, and chest physiotherapy use to be associated with rapid response team activation (odds ratio [OR] >3 doses albuterol: 8.36 [95% confidence interval (CI): 1.99-35.10], P = .048; OR >3 doses hypertonic saline: 13.94 [95% CI: 4.32-44.92], P = .001); OR percussion and postural drainage: 5.06 [95% CI: 1.88-13.63], P = .017). A varied approach to the management of bronchiolitis in both standard-risk and high-risk children occurred institutionally. Bronchodilators and steroids continue to be used frequently despite practice recommendations and regardless of risk status. More research is needed on management strategies in patients at high-risk for severe disease.

Social determinants of health influence preschool and caregiver experiences during symptoms and exacerbations of wheezing

BackgroundSocial determinants of health have been inadequately studied in preschool children with wheezing and their caregivers but may influence the care received. ObjectiveTo evaluate the symptom and exacerbation experiences of wheezing preschool children and their caregivers, stratified by risk of social vulnerability, over 1 year of longitudinal follow-up. MethodsA total of 79 caregivers and their preschool children with recurrent wheezing and at least 1 exacerbation in the previous year were stratified by a composite measure of social vulnerability into “low” (N = 19), “intermediate” (N = 27), and “high” (N = 33) risk groups. Outcome measures at the follow-up visits included child respiratory symptom scores, asthma control, caregiver-reported outcome measures of mental and social health, exacerbations, and health care utilization. The severity of exacerbations reflected by symptom scores and albuterol use and exacerbation-related caregiver quality of life were also assessed. ResultsPreschool children at high risk of social vulnerability had greater day-to-day symptom severity and more severe symptoms during acute exacerbations. High-risk caregivers were also distinguished by lower general life satisfaction at all visits and lower global and emotional quality of life during acute exacerbations which did not improve with exacerbation resolution. Rates of exacerbation or emergency department visits did not differ, but intermediate- and high-risk families were significantly less likely to seek unscheduled outpatient care. ConclusionSocial determinants of health influence wheezing outcomes in preschool children and their caregivers. These findings argue for routine assessment of social determinants of health during medical encounters and tailored interventions in high-risk families to promote health equity and improve respiratory outcomes.

Abstract 15304: Apical Ballooning Syndrome in the Setting of Severe Chronic Obstructive Pulmonary Disease Exacerbation

Apical ballooning syndrome (ABS), also known as Takotsubo cardiomyopathy, is a form of acute dilated cardiomyopathy associated with excessive catecholamine release. A 74-year-old female, chronic smoker with previously diagnosis of obstructive lung disease presented in the emergency department with severe shortness of breath and increase sputum production for the last 24hr. The patient was diagnosed with severe COPD exacerbation and received multiple doses of albuterol, methylprednisolone, ipratropium bromide/albuterol, and azithromycin. Despite this, the patient remained tachypneic and tachycardic with signs of impending respiratory failure. She was transferred to the ICU and intubated. After intubation, the patient received a continuous albuterol nebulizer, methylprednisolone, and ceftriaxone. A few hours later, the patient complained of chest pain, and EKG was done showing T wave inversion in lateral leads, troponin levels were 1.08 ng/mL (ULN 0.12ng/mL), and 2D Echo showed EF 50-55%, apical ballooning with dyskinesia, and inferior wall hypokinesis. Left heart catheterization showed non-obstructive coronary artery disease with 50% stenosis on the left anterior descending artery and distal ostial artery. Based on the previously recommended criteria, the diagnosis of the ABS was made. The patient had resolution of symptoms and echocardiogram findings after follow up. Although albuterol acts mainly on beta-2 receptors, cross-activation of beta-1 receptors can potentially lead to tachycardia. Previous case reports also support that excessive albuterol use in cases of asthma and COPD exacerbation may lead to ABS. This case may raise awareness that the extensive use of albuterol could have dramatic effects. Early switch to beta-2 agonist with higher specificity such as levalbuterol could be a reasonable approach in patients with severe COPD exacerbation.

Abstract 13293: Albuterol and Hyperthyroidism as Potential Causes of Stress Cardiomyopathy

Introduction Takotsubo cardiomyopathy (TCM) is a recognized reversible process associated with emotional or physical stressors characterized by left ventricular apical ballooning in the absence of obstructive coronary artery disease. We present a unique case of TCM after albuterol use in the setting of hyperthyroidism. Results A 74-year-old woman with history of hyperthyroidism and asthma presented with acute substernal chest pain and progressive dyspnea. She was diagnosed with an asthma exacerbation, started oral prednisone 3 days before presentation, and reported using 16 puffs of her albuterol inhaler the day before. Examination revealed blood pressure 157/100 mmHg, heart rate 135 beats per minute, respiratory rate of 35 breaths per minute, and SpO2 94% on a 5-liter nasal cannula. Lung exam revealed bilateral end-expiratory wheezes, and she appeared in respiratory distress. The remainder of the exam was unremarkable, including cardiac exam. ECG revealed atrial tachycardia with ST elevations in the anterolateral leads concerning for injury. High sensitivity troponin was 1484 ng/L (ref &lt;19), free T4 level 3.63 ng/dL (ref 0.56-1.64 ng/dL), TSH &lt;0.02 μU/mL (ref 0.35-3.30 μU/mL ) with TSH-receptor Ab 8.62 IU/L (ref &lt;1.75 IU/L) consistent with worsening hyperthyroidism when compared to one month prior (free T4: 1.19 ng/dL; TSH: 0.84 μU/mL/mL). Emergent cardiac catheterization showed non-obstructive coronary artery disease and reduced ejection fraction (EF) of 30% with akinesia of the anterolateral, apical, and diaphragmatic segments consistent with TCM. She had a full recovery of systolic function noted on repeat echocardiogram 10 weeks after treatment with guideline-directed therapy. Conclusion TCM is primarily driven by a high catecholamine state that, paradoxically, increases β-2 adrenergic receptor inhibitory signaling, thus, causing preferential depression of apical myocardial function possibly due to topographic receptor distribution. Hyperthyroidism mimics a state of adrenergic excess partially mediated by the upregulation of β-adrenergic receptors by thyroid hormones, and the use of β-2 agonists potentiated the development of TCM.

A Predictive Machine Learning Tool for Asthma Exacerbations: Results from a 12-Week, Open-Label Study Using an Electronic Multi-Dose Dry Powder Inhaler with Integrated Sensors.

Machine learning models informed by sensor data inputs have the potential to provide individualized predictions of asthma deterioration. This study aimed to determine if data from an integrated digital inhaler could be used to develop a machine learning model capable of predicting impending exacerbations. Adult patients with poorly controlled asthma were enrolled in a 12-week, open-label study using ProAir® Digihaler®, an electronic multi-dose dry powder inhaler (eMDPI) with integrated sensors, as reliever medication (albuterol, 90 µg/dose; 1-2 inhalations every 4 hours, as needed). Throughout the study, the eMDPI recorded inhaler use, peak inspiratory flow (PIF), inhalation volume, inhalation duration, and time to PIF. A model predictive of impending exacerbations was generated by applying machine learning techniques to data downloaded from the inhalers, together with clinical and demographic information. The generated model was evaluated by receiver operating characteristic area under curve (ROC AUC) analysis. Of 360 patients included in the predictive analysis, 64 experienced a total of 78 exacerbations. Increased albuterol use preceded exacerbations; the mean number of inhalations in the 24-hours preceding an exacerbation was 7.3 (standard deviation 17.3). The machine learning model, using gradient-boosting trees with data from the eMDPI and baseline patient characteristics, predicted an impending exacerbation over the following 5 days with an ROC AUC of 0.83 (95% confidence interval: 0.77-0.90). The feature of the model with the highest weight was the mean number of daily inhalations during the 4 days prior to the day the prediction was made. A machine learning model to predict impending asthma exacerbations using data from the eMDPI was successfully developed. This approach may support a shift from reactive care to proactive, preventative, and personalized management of chronic respiratory diseases.

The Potential Synergistic Risk of Albuterol and Vasoactives in Acute Lung Injury Trials.

Critically ill patients are often prescribed both inhaled beta-agonists and intravenous vasoactive; however, the interaction of the additive beta-agonist effects of these 2 agents remains largely uncharacterized. The purpose of this study was to evaluate how concomitant use of albuterol and vasoactive or inotropes affected ventilator-free days (VFDs) by re-analyzing the data from the Albuterol to Treat Acute Lung Injury (ALTA) trial. In this study, subjects were grouped to albuterol-vasoactive (n = 84) versus (vs) placebo-vasoactive (n = 62). Ventilator-free days, intensive care unit (ICU)-free days, organ failure-free days, cardiovascular adverse events, and 90-day mortality were compared. The primary outcome was VFDs. Patients in the albuterol-vasoactive group had significantly fewer VFDs than patients in the placebo-vasoactive group (11 vs 19, P = 0.05). Patients in the albuterol-vasoactive group also had significantly fewer ICU-free days (9.5 vs 18.5, P = .006). The 90-day mortality was similar between groups (36.9% vs 27.4%, P = .20). Similarly, no significant difference in cardiac adverse events between the groups (14.3% vs 11.3%, P = 0.59). This study has shown fewer VFDs for patients who received both vasoactive and albuterol. There were also fewer ICU-free days when compared to those on vasoactive only. Given the common use of both agents, a prospective evaluation of the additive adverse effects of beta-agonism is warranted.

Albuterol–Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma

BackgroundAs asthma symptoms worsen, patients typically rely on short-acting β2-agonist (SABA) rescue therapy, but SABAs do not address worsening inflammation, which leaves patients at risk for severe asthma exacerbations. The use of a fixed-dose combination of albuterol and budesonide, as compared with albuterol alone, as rescue medication might reduce the risk of severe asthma exacerbation.MethodsWe conducted a multinational, phase 3, double-blind, randomized, event-driven trial to evaluate the efficacy and safety of albuterol–budesonide, as compared with albuterol alone, as rescue medication in patients with uncontrolled moderate-to-severe asthma who were receiving inhaled glucocorticoid-containing maintenance therapies, which were continued throughout the trial. Adults and adolescents (≥12 years of age) were randomly assigned in a 1:1:1 ratio to one of three trial groups: a fixed-dose combination of 180 μg of albuterol and 160 μg of budesonide (with each dose consisting of two actuations of 90 μg and 80 μg, respectively [the higher-dose combination group]), a fixed-dose combination of 180 μg of albuterol and 80 μg of budesonide (with each dose consisting of two actuations of 90 μg and 40 μg, respectively [the lower-dose combination group]), or 180 μg of albuterol (with each dose consisting of two actuations of 90 μg [the albuterol-alone group]). Children 4 to 11 years of age were randomly assigned to only the lower-dose combination group or the albuterol-alone group. The primary efficacy end point was the first event of severe asthma exacerbation in a time-to-event analysis, which was performed in the intention-to-treat population.ResultsA total of 3132 patients underwent randomization, among whom 97% were 12 years of age or older. The risk of severe asthma exacerbation was significantly lower, by 26%, in the higher-dose combination group than in the albuterol-alone group (hazard ratio, 0.74; 95% confidence interval [CI], 0.62 to 0.89; P=0.001). The hazard ratio in the lower-dose combination group, as compared with the albuterol-alone group, was 0.84 (95% CI, 0.71 to 1.00; P=0.052). The incidence of adverse events was similar in the three trial groups.ConclusionsThe risk of severe asthma exacerbation was significantly lower with as-needed use of a fixed-dose combination of 180 μg of albuterol and 160 μg of budesonide than with as-needed use of albuterol alone among patients with uncontrolled moderate-to-severe asthma who were receiving a wide range of inhaled glucocorticoid-containing maintenance therapies. (Funded by Avillion; MANDALA ClinicalTrials.gov number, NCT03769090.)

School-based Stock Inhaler Programs and Neighborhood Disadvantage.

Ensuring students with asthma residing in disadvantaged communities have access to rescue medication (albuterol) is important. Using the Area Deprivation Index (ADI), we examined relationships between albuterol use and neighborhood deprivation among schools participating in the Pima County (Arizona) Stock Inhaler Program. Schools were categorized into quartiles based on their census block ADI. A hurdle regression examined associations between ADI and stock inhaler use after controlling for school characteristics. Among 228 participating schools, only those in the second worst ADI quartile were more likely to use a stock inhaler than those in the most deprived quartile (referent), OR 1.9 (95% CI 1.2-2.9). Middle schools had 2.1 times higher odds (95% CI 1.3-3.4) of ever using a stock inhaler than elementary schools (referent). Students attending schools in the second most deprived communities, as opposed to most deprived, may have the most tenuous albuterol access.

As-Needed Use of Short-Acting β2-Agonists Alone Versus As-Needed Use of Short-Acting β2-Agonists Plus Inhaled Corticosteroids in Pediatric Patients With Mild Intermittent (Step 1) Asthma: A Cost-Effectiveness Analysis

Although the efficacy of the as-needed use of short-acting β2-agonists (SABAs) plus inhaled corticosteroids (ICS) for treating children with mild intermittent asthma has been demonstrated, evidence of its cost-effectiveness is scarce. The aim of the present study was to compare the cost-effectiveness of the as-needed use of SABAs alone versus the as-needed use of SABAs plus ICS in children 5 to 11 years old with mild intermittent (step 1) asthma but suffering from an exacerbation of asthma symptoms. A decision-analysis model was adapted. Effectiveness parameters were obtained from a randomized clinical trial. Cost data were obtained from hospital bills and from the national manual of drug prices in Colombia. The study was carried out from the perspective of the national health care system in Colombia. The main outcome of the model was a first course of prednisone for an asthma exacerbation (AE). Compared with the use of SABAs alone, the as-needed use of SABAs plus ICS was associated with lower overall treatment costs (US$17.99 vs US$27.94 mean cost per patient) and a higher probability of a lack of a requirement for a first course of prednisone (0.6500 vs 0.5100), thus showing dominance. In Colombia, compared with the use of albuterol alone, the use of beclomethasone dipropionate added to albuterol as needed for symptom relief is cost-effective in children 5 to 11 years old with mild intermittent (step 1) asthma, because it involves a higher probability of a lack of a requirement for prednisone for AE at lower total treatment costs.

Variation in Prehospital Protocols for Pediatric Respiratory Distress Management in the United States.

This study aimed to compare statewide emergency medical services protocols for the management of pediatric respiratory distress. We performed a descriptive study of emergency medical services protocols for the management of pediatric respiratory distress in the United States, excluding those without model or mandatory protocols. We compared medication recommendations for specific disease processes, including asthma, croup, epiglottitis, anaphylaxis, generalized respiratory distress, intubation, and drug assisted intubation. Thirty-four state protocols were included. All had protocols to address the management of pediatric respiratory distress. There was high agreement in albuterol use for bronchospasm and epinephrine use in anaphylaxis. Epinephrine was recommended in all anaphylaxis protocols, 27 croup protocols (79%), and 3 epiglottitis protocols (9%). Six states (18%) called for albuterol in patients with generalized respiratory distress. Steroid recommendations and indications had variance among states; 26 states (76%) allowed steroid use in patients with asthma, 19 states (56%) recommended steroid use in anaphylaxis, and 11 (32%) recommended steroid use in croup protocols. The route for steroid administration also varied among protocols. Five states (15%) allowed continuous positive airway pressure application in pediatric patients, whereas endotracheal intubation and rapid sequence intubations had varying requirements as well as recommendations for use. Twelve (35%) listed impending or current respiratory failure as an indication, whereas other states had specific markers, such as Glasgow Coma Scale or oxygen saturation, as indications. All included states had specific recommendations for the management of pediatric respiratory distress. There was consistency in recommendations for albuterol use for wheezing and epinephrine use for anaphylaxis. However, there was wide variability in other uses for epinephrine, steroid administration, continuous positive airway pressure use, and specific treatments for croup and epiglottitis. The findings of this study provide a base for important future evidence-based protocol developments and changes in prehospital pediatric respiratory distress treatment.

What Is the Role of Shared Decision-Making With Parents of Children With Bronchiolitis?

What Is the Role of Shared Decision-Making With Parents of Children With Bronchiolitis?

An Adolescent with Respiratory Distress

A 17-year-old adolescent male with a history of well-controlled mild intermittent asthma requiring infrequent albuterol use, allergic rhinitis, and severe allergies to sesame seeds, tree nuts, and shellfish presented with cough, fever, and emesis for 5 days. Hospitalized for management of an asthma exacerbation and atypical pneumonia, he was treated with systemic corticosteroids, inhaled albuterol, and empirical antibiotic therapy. On the second hospital day, however, he became increasingly dyspneic and hypoxemic, and diffuse coarse breath sounds were appreciated on auscultation of the lungs.

Impact of Enteral Albuterol on Bradycardic Events After Acute Cervical Spinal Cord Injury.

Acute cervical spinal cord injury (ACSCI) is commonly complicated by spinal shock, resulting in hemodynamic instability characterized by bradycardia and hypotension that can have fatal consequences. Current guidelines recommend the use of intravenous beta and dopamine agonists, such as norepinephrine and dopamine, respectively. We sought to determine whether enteral albuterol would be a safe and feasible treatment for bradycardia without an increase in the occurrence of known side effects of albuterol in patients with ACSCI. A retrospective review of patients with ACSCI admitted to an intensive care unit at a level I trauma center and treated with enteral albuterol was conducted. Patients were excluded for the following reasons: pure beta blocker use prior to injury, concurrent use of pacemaker, age of less than 18years, or agemore than 75years. As part of the standard of care, all patients underwent mean arterial pressure (MAP) augmentation to reach a goal of greater than 85mm Hg during the first 7days post injury. All eligible patient charts were reviewed for demographic characteristics, daily minimum and maximum heart rate and MAP, and concomitant vasoactive medication use. Bradycardia and tachycardia were defined as heart rate less than 60 beats per minute (bpm) and greater than 100bpm, respectively. Factors found to be associated with bradycardia on univariate analysis were entered into a multivariable generalized estimating equation analysis to determine factors independently associated with bradycardia during the study period. There were 58 patients with cervical ASCI (age 45 ± 18years, 76% men) admitted between January 1, 2016, and December 31, 2017, that met the study criteria. The mean time to initiation of albuterol was 1.5 ± 1.7days post injury, with a duration of 9.3 ± 4.5days and a mean daily dosage of 7.8 ± 4.5mg. Bradycardia was observed in 136 of 766 patient days (17%). There were a few episodes of hyperglycemia (1%) and tachycardia (3%), but no episodes of hypokalemia. In a multivariable analysis, female sex (P = 0.006) and American Spinal Cord Injury Association grade A, B, or C (P < 0.001) were associated with a higher risk of developing bradycardia, whereas dosage of albuterol (P = 0.009) and norepinephrine use (P = 0.008) were associated with a lower risk of developing bradycardia. Albuterol administration in ASCI is a safe and feasible treatment for bradycardia, given that no significant side effects, such as hyperglycemia, hypokalemia, or tachycardia, were observed. The administration of enteral albuterol was well tolerated and, in a dose-dependent manner, associated with a lower occurrence of bradycardia. Further prospective trials for the use of enteral albuterol after SCI are warranted.