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3 hours ago, GetMeOuttaThisMess said:

 

People with documented RAD. Anytime they have a cough/asthmatic bronchitis do you give them a steroid door prize, and if so, how much of what?

 

Depends on if I have a good best flow already documented (many have none despite the diagnosis by another provider), what their peak flow is at that visit, do they respond really well to albuterol, and how do they feel (SOB, DOE, or is just the cough keeping you awake/annoying you? Sometimes it just “use your albuterol scheduled every 4 hours, sometimes it’s steroid. In a adult I use minimum of 40 for 3 days with a follow up on day 3. I think literature says 5 days is the minimum and could take up to 10. I would say I average 50mg for 5 days in adults (averaging their size, severity, how they look at follow up). Kids I’m more likely to give steroids and tack on a extra couple days to prevent rebound if they don’t give me the warm fuzzies and have more than exercise induced asthma. 

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What I've typically done over the years, and have seen done during my time with others in the ED, is anywhere from 2-5 days.  I typically will give 20 mg. prednisone b.i.d. during that time.  I wanted to pull out my hair today, which is hard to do since I keep what is left short anyway, with a RAD pt., smells like a chimney, who can't figure out why she can't sleep at night because of the cough and isn't getting better?  We don't do follow up so it would be left to their PCP.  I know not what this "peak flow" is of which you speak oh wise man.  Heck, I can't even get my folks to purchase a thermometer.  On a serious note, it's about time to try the "Uh, do you smoke?" routine while listening to the lungs of those who do and just leave it as an open-ended question.

To answer my own question, if you're squeaking and I know that someone somewhere told you that you have asthma then you get the door prize, well, except during flu season as per the other thread.

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6 minutes ago, GetMeOuttaThisMess said:

What I've typically done over the years, and have seen done during my time with others in the ED, is anywhere from 2-5 days.  I typically will give 20 mg. prednisone b.i.d. during that time.  I wanted to pull out my hair today, which is hard to do since I keep what is left short anyway, with a RAD pt., smells like a chimney, who can't figure out why she can't sleep at night because of the cough and isn't getting better?  We don't do follow up so it would be left to their PCP.  I know not what this "peak flow" is of which you speak oh wise man.  Heck, I can't even get my folks to purchase a thermometer.  On a serious note, it's about time to try the "Uh, do you smoke?" routine while listening to the lungs of those who do and just leave it as an open-ended question.

To answer my own question, if you're squeaking and I know that someone somewhere told you that you have asthma then you get the door prize, well, except during flu season as per the other thread.

I’ll probably err on the side of more prednisone in the ED. All my experience thus far has been in the FM clinic, where they’ll have a peak flow (poor man’s PFT) and I have the benefit of seeing any visit to any military facility, including the ED, on my EMR.

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There are many factors to consider including peak flow values at time of exacerbation, past spirogram/PFT data, frequency and past history of exacerbations requiring ER visits or hospitalization. It is also critical to review proper inhaler technique and to make sure the patient is using his or her rescue inhaler/nebulizer correctly.  Physical exam with observation of work of breathing, auscultation with whezing rhonchi or diminished breath sounds is also crucial.

You may be surprised at how many ways a MDI inhaler can be used improperly. I've seen it all! 

When needed... I typically prescribe 40 mg x 5 days, 20 mg x days, if the patient has a history of multiple exacerbations, I may prescribe a longer taper. 

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3 hours ago, d2305 said:

I  give 60mg/day X 5 days or 8mg decadron im.  Pediatric prednisolone 1mg/kg x 5 days and an Rx of singulair.

Out of curiosity, why not just give the dexamethasone as a single po dose?  Peak activity is relatively the same (5x half-life).  I acknowledge that there may be more money to be made by administering an injection (not being cynical).

I'm currently using the po dexamethasone in lieu of b.i.d. 20 mg. prednisone for 2 days for odynophagia relief.  Why?  I don't know, other than a review that I saw in my abstracts about benefit with a single dose compared with placebo (why do we compare to placebo and not some other similar, cheaper drug?) and depending on which way the wind is blowing and the day of the week.

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5 hours ago, d2305 said:

Or why do we use a medrol dose pak some days?

I don't simply because of complaints in years past about cost.  Prednisone they'll almost hand out for free.  Per GoodRx.com, Medrol DP $17-$20 locally.  Dexamethasone, 2 4 mg. tabs as a single dose for odynophagia is $2-4.50 in my neighborhood.  Prednisone 20 mg. for 4 tabs (b.i.d for 2 days) is <$2-5.30.

Generic Tamiflu for grins/giggles is $52-93 for 10 tabs.

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Depends on so many things. Is it a true acute asthma exacerbation? If so how severe?

If it's just RAD with that persistent dry cough and minimal or no wheezing, I dont usually do steroids. Albuterol and reassurance.

If it is a clinical exacerbation with wheezing on exam, decreased peak flow, then pred 20mg BID x 5 days. With or without nebs based on severity.

In kiddos I'll do weight-based decadron for 4-5 days.

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In the various settings:

1) Pediatric ICU:  it'll be 1mg/kg IV q6 hours, especially if they're sick enough to be on BiPAP.  At this point I'm trying to prevent intubation so they'll be on everything from mag drips to ketamine - I HATE intubating asthmatics - they are a pain in the ass to manage.  If they're only on high flow or CPAP, or even just high amount of continuous albuterol, I'll still probably do 1mg/kg IV q6, but I wouldn't feel as strongly about it.  We've had to put one kid on ECMO for asthma, and that was not a fun experience - literally had to sit next to that kid all night.

2) Inpatient but not ICU:  pred daily or dexamethasone x 2.  I personally like dex because I can give them a dose and send them home and I know it will last a few days.  At that point the PCP can decide to continue or stop based on how they sound.  The less meds I discharge them with, the better, just for compliance sake.  I don't believe there's been any study that shows superiority of dex vs pred as far as I know.

3) Outpatient:  I just give them dex in the office and see them back in a couple of days to see how they are doing.  For well known asthmatics who I know won't get better, I'll do a seven day course of pred and see them again in a week.

4) Pediatric ED:  Any one of the above depending on how sick they are.

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