Another Flu discussion

[GetMeOuttaThisMess]

Primary complication of influenza is an opportunistic bacterial pneumonia. You have a patient with known reactive airway disease and for the sake of this discussion is using their MDI >2x/week during a good week. O2 sat is ok and no respiratory distress but mild exp. wheezing noted. General standard of care is a short burst of oral steroids for RAD patients with pulmonary sx. Because of the influenza you have to consider risk of immunosuppression. We hadn’t discussed previously with SP’s during monthly required meetings so I sent a burst email to inquire and answers were consistent. What do you do?

[Guest ral]

I tend to not let other stuff get in the way of treating the stuff that I know how to treat.

Probably cryptic for some of you.  Others will know what I am saying.

[lkth487]

If it's a peds patient, steroids and albuterol.  See them again in two days.  Wouldn't do a cxr or any other tests unless the condition worsens.  I think your NNT is too high for other interventions. 

[GetMeOuttaThisMess]

Question rephrased.  Yes or no to steroids in this setting?

[lkth487]

Yes*

 

*Usually, I'll give puffs while in office and see if that improves symptoms/exam.  If the wheezing improves, I'll send home with puffs around the clock and a short steroid course and follow up in 48 hours.  If the puffs don't help, then I wouldn't do steroids.  

[Guest ral]

1 hour ago, GetMeOuttaThisMess said:

Question rephrased.  Yes or no to steroids in this setting?

Yes.

[camoman1234]

3 hours ago, lkth487 said:

Yes*

 

*Usually, I'll give puffs while in office and see if that improves symptoms/exam.  If the wheezing improves, I'll send home with puffs around the clock and a short steroid course and follow up in 48 hours.  If the puffs don't help, then I wouldn't do steroids.  

What puffs are you speaking of? SABA?If so that has not bearing on if you give steroids or not. Beta-2 agonist have a much different MOA than pulmicort or flovent, as you know. RAD/asthma is a 2 part story, smooth muscle constriction plus mucosal inflammation which the latter needs steroids. Sure giving then a neb (SABA or SABA + SAMA) in office is great so you may assess their response, but that does not tell me if I need to give a steroid or not. I would give a steroid in this case, PO for older kid or adult or pulmicort 0.25 mg BID x 2 weeks for a younger kiddo (1-8 yrs), do NOT mix with any other solution.

P.S. I hope when giving puffs in office you are using a spacer with or without a mask as you might as well throw the inhaler in the trash is you are not using a spacer (and no the 2 finger technique is very difficult and puffers should never be used in exacerbations as they are not effective).

[LT_Oneal_PAC]

3 minutes ago, camoman1234 said:

What puffs are you speaking of? SABA?If so that has not bearing on if you give steroids or not. Beta-2 agonist have a much different MOA than pulmicort or flovent, as you know. RAD/asthma is a 2 part story, smooth muscle constriction plus mucosal inflammation which the latter needs steroids. Sure giving then a neb (SABA or SABA + SAMA) in office is great so you may assess their response, but that does not tell me if I need to give a steroid or not. I would give a steroid in this case, PO for older kid or adult or pulmicort 0.25 mg BID x 2 weeks for a younger kiddo (1-8 yrs), do NOT mix with any other solution.

P.S. I hope when giving puffs in office you are using a spacer with or without a mask as you might as well throw the inhaler in the trash is you are not using a spacer (and no the 2 finger technique is very difficult and puffers should never be used in exacerbations as they are not effective).

Perhaps a bit harsh? Surely we aren’t asking people to write a school report when responding to these types of questions. I think he was oversimplying since the question was reduced to a simple yes or no. I suspect he means if the albuterol puffs did not help it just means further eval, not that it eliminates the use of steroids. At least, I would do the same.

[lkth487]

12 minutes ago, camoman1234 said:

What puffs are you speaking of? SABA?If so that has not bearing on if you give steroids or not. Beta-2 agonist have a much different MOA than pulmicort or flovent, as you know. RAD/asthma is a 2 part story, smooth muscle constriction plus mucosal inflammation which the latter needs steroids. Sure giving then a neb (SABA or SABA + SAMA) in office is great so you may assess their response, but that does not tell me if I need to give a steroid or not. I would give a steroid in this case, PO for older kid or adult or pulmicort 0.25 mg BID x 2 weeks for a younger kiddo (1-8 yrs), do NOT mix with any other solution.

P.S. I hope when giving puffs in office you are using a spacer with or without a mask as you might as well throw the inhaler in the trash is you are not using a spacer (and no the 2 finger technique is very difficult and puffers should never be used in exacerbations as they are not effective).

Yes, I mean SABA, and always with a spacer :).  The reason I would use the SABA first is to see if there was indeed a component of RAD involved.  I would expect the wheezing to improve with a SABA.  The treatment for a flare is both a Saba and a short course of steroids but if there is no response, I wouldn't give steroids think about other causes of wheezing (foreign body, pna can sometimes cause it, etc etc).  If there is a response, I would actually do dexamethasone x1 PO in the office, and albuterol ar home, and see them in 48 hours, or send them home with daily prednisolone PO and albuterol and see them again in 48 hours.  

[camoman1234]

2 minutes ago, LT_Oneal_PAC said:

Perhaps a bit harsh? Surely we aren’t asking people to write a school report when responding to these types of questions. I think he was oversimplying since the question was reduced to a simple yes or no. I suspect he means if the albuterol puffs did not help it just means further eval, not that it eliminates the use of steroids. At least, I would do the same.

If one takes good medicine as harsh and gets hurt over a simple question and answer then you need to change professions. We ALL get corrected on something and that is for the good of the patient. We are here for the patients and not to cry over if we do not like how someone responded to our question. I was sincerely trying to help and also understand what his/her thinking was so I have to response in a way to get some answers. I see nothing wrong with "writing a school report" as practicing medicine is an art and takes a lifetime of learning. Pathology/physiology/MOA, etc are just very crucial in treating patients as understanding the basics will help one treat better. I am sure lkth487 (being a physician) as a very great concept on MOA/pathology/physiology, but it does not hurt one to tell someone why they are doing something and what their reasons are behind it. I do not like when someone corrects me on a topic, but does not tell me why. I was just explaining the 2 parts of RAD/asthma as it is a very important part of treatment.  

[LT_Oneal_PAC]

Listen, be a knob if you like. It’s your business. I personally am too busy giving good patient care and staying up to date to write a multi paragraph article on the forum (for a yes/no question), much less chastise others for slightly incomplete answers.

sorry for the derail OP. Continue on please

[lkth487]

By the way, I would give PO steroids to the kid if I thought it was a RAD exacerbation, regardless of age - whether it's 6 months or 16 years.  I wouldn't do pulmicort over oral steroids for younger kids - if they need steroids for an exacerbation, they need steroids.  And oral should be the standard of care unless they are sick enough to be admitted on continuous albuterol and need Q6 IV steroids. 

[camoman1234]

1 minute ago, lkth487 said:

By the way, I would give PO steroids to the kid if I thought it was a RAD exacerbation, regardless of age - whether it's 6 months or 16 years.  I wouldn't do pulmicort over oral steroids for younger kids - if they need steroids for an exacerbation, they need steroids.  And oral should be the standard of care unless they are sick enough to be admitted on continuous albuterol and need Q6 IV steroids. 

"I would give a steroid in this case, PO for older kid or adult or pulmicort 0.25 mg BID x 2 weeks for a younger kiddo (1-8 yrs), do NOT mix with any other solution."

Yes, you are right that is the standard of care. I missed putting that in my comment. I do give pulmicort (for home use) and dexamethasone in office with kiddos. 

[GetMeOuttaThisMess]

Its a generic patient, no nebs or other stepped RAD treatment is being considered with this question. Do you allow the immunosuppression effect to override the anti-inflammatory effect in the setting of flu with secondary concern for possible pneumonia?

[lkth487]

No.  The studies are unclear and steroids are not harmless. 

[JustinPA]

I would probably do a single dose of PO Decadron and a prescription for Tamiflu in that situation.  I can't imagine a few days worth of steroid activity in a healthy individual is enough to cause significant immunosuppression.  Steroids are routinely used in viral croup and tonsillitis without any issues.  On a side note, if you are giving PO Decadron IV/IM solution remember to increase the dose because it only has a 75 percent bioavailability  compared to normal PO Decadron. I was unaware of this until a couple weeks ago when a pharmacist mentioned it to me.  I had always assumed they were equivalent.  

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4418677/

[lkth487]

I hate tamiflu!  

 

https://www.sciencedirect.com/science/article/pii/S1198743X15006813

A single dose of steroids PROBABLY won't hurt but if you look at it in aggregate, especially for a self limiting infection like the flu (in an otherwise normal person), I think the downsides outweigh the benefits.  Especially when those doses add up.  Viral croup is a different beast in my opinion and I don't think you can compare - you're more actively worried about the airway in that situation and so your NNT and benefits/risks ratio is way different   

Thanks for the link about Decadron bioavailability - I didn't know that either!  And I use decadron quite a bit. 

[JustinPA]

In this situation aren't we using the steroids for the asthma exacerbation that is secondary to the influenza infection though?  I agree that the steroids shouldn't be used for routine influenza.  A good amount of asthma exacerbations are triggered by viral URIs, and those asthma exacerbations are still treated with PO steroids.  In this situation I'm assuming the issue is that they have a positive influenza test, and there is concern that the steroids will decrease the patient's ability to fight off the influenza or increase their chances of getting a secondary bacterial pneumonia.  I brought up the use of steroids for viral croup and tonsillitis because in those situations it doesn't seem to inhibit the patient's ability to fight off the viral infection or increase their chances for secondary infection, at least that I have ever heard of.  

[JustinPA]

This study is kind of similar to what we are discussing:

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0032280

[JustinPA]

The link from Ikth487 suggests that people in general with influenza do worse when given steroids, but unfortunately doesn't answer the question of if asthmatics with current exacerbation and influenza infection do better with vs without steroids.  I still think in this situation where the patient has known asthma and influenza with wheezing that I would probably still treat them like an asthma exacerbation with the steroids but also give them the Tamiflu, regardless how many days out from the onset of flu symptoms they were, to help mitigate the effects of the steroids on their ability to fight off the flu. 

[lkth487]

I think 100% I would give steroids for asthma exacerbation.  Thats why I replied in the affirmative in the earlier post.  But the follow up post from getmeoutofthismess said that we are assuming it is not RAD.  So assuming just influenza with no RAD component, I would not give them steroids purely for the influenza.

[JustinPA]

Oh I missed that part, I apologize. I agree with that.

[GetMeOuttaThisMess]

I'm not making myself clear here I don't think:

1.  Flu patient

2.  Hx. of RAD which is poorly controlled due to having to use MDI >2x/week (Rules of 2 criteria)

3.  Mild wheezing on examination o/w no acute respiratory distress (assume that they don't even know that they're wheezing)

4.  You typically would give a short burst of oral steroid due to exacerbation of RAD due to presence of wheezing in any other patient with non-influenza bronchitis per pulmonary

5.  The question is does the presence of influenza, and the inherent risk for an opportunistic bacterial pneumonia as a result of influenza, alter your normal 4. above response?

[lkth487]

OK, that's more clear.  The answer for me is no.  I would give steroids in this case.  Unless there is some other more significant underlying condition that would preclude steroids, I would absolutely treat this patient with steroids.  Many RAD exacerbations (especially in children) are caused by viral infections - they can all lead you to have an increased risk of superimposed bacterial pneumonia.   If the presence of a viral process precluded giving of oral steroids, we would almost never end up treating RAD in kids with steroids.  

 

Obv. long term they need better control, so would start that as well.

[lkth487]

I also don't ever get DFAs (MAYBE if they are ICU level sick) and very rarely test for the flu.  So I wonderfully avoid this problem in the first place.   ;)

I'm right now trying to run a QI project at my hospital to decrease DFA usage in general.