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Internal Medicine 101

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  1. Pneumonia 

    Community-Acquired Pneumonia
    9 Topics
    |
    3 Quizzes
  2. Venous Thromboembolic Disease
    Acute Management of Pulmonary Embolism
    12 Topics
    |
    2 Quizzes
  3. Acute Management of DVT
    10 Topics
    |
    2 Quizzes
  4. Diabetes and Hyperglycemia
    Hyperglycemia in Hospitalized Patients
    11 Topics
    |
    2 Quizzes
  5. Hyperglycemic Crisis: Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome
    13 Topics
    |
    3 Quizzes
  6. Pulmonary Exacerbations
    Chronic Obstructive Pulmonary Disease Exacerbation
    10 Topics
    |
    3 Quizzes
  7. Asthma Exacerbation
    15 Topics
    |
    3 Quizzes

Participants 396

  • Allison Clemens
  • April
  • ababaabhay
  • achoi2392
  • adhoward1
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Lesson 7, Topic 8
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Pharmacological Management

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Pharmacological management of asthma exacerbations involves a complex interplay of medications aimed at relieving bronchoconstriction, reducing inflammation, and addressing underlying triggers. This section will detail the evidence-based pharmacological interventions, including dosing (both adult and pediatric), rationale, adverse effects, and specific considerations for various formulations.

Bronchodilators

Short-Acting Beta-Agonists (SABAs)

Albuterol

  • Adult Dosing: Inhaler: 2-4 puffs every 4-6 hours; Nebulizer: 2.5-5 mg every 4-8 hours
  • Pediatric Dosing: Inhaler: 1-2 puffs every 4-6 hours; Nebulizer: 0.15 mg/kg (min 2.5 mg/dose) every 4-6 hours
  • Rationale: Rapid bronchodilation; first-line treatment
  • Adverse Effects: Tremors, tachycardia, palpitations, hypokalemia
  • Formulations: Metered-dose inhaler (MDI), nebulizer solution

Levalbuterol

  • Adult Dosing: Inhaler: 2 puffs every 4-6 hours; Nebulizer: 0.63-1.25 mg every 6-8 hours
  • Pediatric Dosing: Nebulizer: 0.31-0.63 mg every 6-8 hours (age-dependent)
  • Rationale: May cause fewer side effects than albuterol
  • Adverse Effects: Similar to albuterol
  • Formulations: MDI, nebulizer solution

Anticholinergics

Ipratropium

  • Adult Dosing: Inhaler: 2 puffs every 6 hours; Nebulizer: 0.5 mg every 6 hours
  • Pediatric Dosing: Nebulizer: 0.25 mg every 6-8 hours (age-dependent)
  • Rationale: Reduces bronchospasm; used in conjunction with SABAs
  • Adverse Effects: Dry mouth, urinary retention, blurred vision
  • Formulations: MDI, nebulizer solution

Corticosteroids

Systemic Corticosteroids

Prednisone

  • Adult Dosing: 40-60 mg orally daily for 5-10 days
  • Pediatric Dosing: 1-2 mg/kg/day in single or divided doses (max 60 mg/day)
  • Rationale: Reduce inflammation; enhance recovery
  • Adverse Effects: Hyperglycemia, hypertension, mood changes

Methylprednisolone

  • Adult Dosing: IV: 40-125 mg
  • Pediatric Dosing: IV: 1-2 mg/kg/dose every 6-12 hours
  • Rationale: For severe exacerbations requiring hospitalization
  • Adverse Effects: Similar to oral corticosteroids

Inhaled Corticosteroids (ICS)

Fluticasone

  • Adult Dosing: Varies by medication and severity; typically used for chronic management
  • Pediatric Dosing: Varies by age and severity
  • Rationale: Not used for acute exacerbation; chronic inflammation control
  • Adverse Effects: Oral thrush, hoarseness

Budesonide

  • Adult Dosing: Nebulizer: 0.5-1 mg twice daily
  • Pediatric Dosing: Nebulizer: 0.25-0.5 mg twice daily (age-dependent)
  • Rationale: Maintenance therapy
  • Adverse Effects: Similar to other ICS


Additional Pharmacological Therapies

Magnesium Sulfate

  • Adult Dosing: IV: 1-2 grams over 15-30 minutes
  • Pediatric Dosing: IV: 25-50 mg/kg (max 2 grams) over 20 minutes
  • Rationale: Used in severe exacerbations; reduces bronchoconstriction
  • Adverse Effects: Flushing, hypotension, respiratory depression

Leukotriene Modifiers

Montelukast

  • Adult Dosing: 10 mg orally once daily
  • Pediatric Dosing: 4-5 mg orally once daily (age-dependent)
  • Rationale: Maintenance therapy; not for acute exacerbation
  • Adverse Effects: Headache, abdominal pain

IV Fluids and Electrolyte Management

  • Rationale: Address dehydration and electrolyte imbalances in severe exacerbations
  • Considerations: Monitor for fluid overload, especially in heart failure patients

Antibiotics

  • Rationale: Not routinely recommended; consider if evidence of bacterial infection
  • Considerations: Select based on suspected pathogen and local resistance patterns

Heliox

  • Rationale: A mixture of helium and oxygen; may improve airflow in severe cases
  • Considerations: Limited availability; used as a rescue therapy

Ketamine

Ketamine is an NMDA receptor antagonist with analgesic, anesthetic, and bronchodilatory properties. It has been considered in specific cases of severe asthma exacerbation where conventional treatments have failed.

Adult Dosing

  • IV: 0.2-0.8 mg/kg over 1-2 minutes; may repeat as needed
  • IM: 4-5 mg/kg; may repeat as needed

Pediatric Dosing

  • IV: 1-2 mg/kg over 1-2 minutes; may repeat as needed
  • IM: 4-5 mg/kg; may repeat as needed

Rationale

  • Bronchodilation: Ketamine may cause bronchodilation in severe asthma.
  • Sedation: Useful in cases requiring mechanical ventilation.

Adverse Effects

  • CNS Effects: Hallucinations, agitation
  • Cardiovascular Effects: Hypertension, tachycardia

 

Parenteral Beta-Agonists

Parenteral beta-agonists, including epinephrine and terbutaline, may be used in life-threatening asthma exacerbations or when inhaled routes are not feasible.

Epinephrine

  • Adult Dosing: IM/SQ: 0.3 mg (1:1000) every 20 minutes; IV: 0.1-0.5 mcg/kg/min
  • Pediatric Dosing: IM/SQ: 0.01 mg/kg (1:1000) every 20 minutes; IV: 0.1-0.5 mcg/kg/min
  • Rationale: Rapid bronchodilation; used in severe, life-threatening cases
  • Adverse Effects: Palpitations, anxiety, tremors

Terbutaline

  • Adult Dosing: SQ: 0.25 mg every 15-30 minutes; IV: 0.1-10 mcg/kg/min
  • Pediatric Dosing: SQ: 0.01 mg/kg every 15-20 minutes; IV: 0.1-10 mcg/kg/min
  • Rationale: Alternative to epinephrine; used in severe cases
  • Adverse Effects: Similar to epinephrine; risk of hypokalemia and hyperglycemia

Summary

Pharmacological management of asthma exacerbations is a multifaceted approach that requires a comprehensive understanding of various therapies, their indications, dosing (including specific considerations for pediatric patients), and potential adverse effects. The integration of bronchodilators, corticosteroids, additional therapies such as magnesium sulfate, and targeted treatments like biologics offers a tailored approach to patient care.