Q. 1. I read with interest these guidelines (1) and have the following clarifications to seek in this context.
1. In the home treatment of asthma exacerbation, why only single nebulizer
treatment is recommended and not three every 20 min as is done with metered dose inhaler?
2. Why inhaled ipratropium bromide has not been included as an adjunct to
inhaled ~2 agonists in the emergency room management of an acute attack of asthma which is severe or poorly responds to inhaled
β2 agonist alone?
3. Why aminophylline (infusion) has been recommended in the treatment of an
acute exacerbation of asthma although the Expert Panel Report II (2) mentions it clearly amongst therapies not recommended. The cited reasons is that inhaled ~2 agonists are 3-4 times more effective than aminophylline and addition of this drug does not result in a greter effect but may increase the adverse effects.
M.K. Tolani,
Consulting Pediatrician,
C-14, Silver Plaza,
Canada Corner, Nasik, india.
REFERENCES
I.
Consensus Guidelines on Management of Childhood Asthma in India. Indian Pediatr 1999; 36: 157-165.
2.
Sly RM. New guidelines for diagnosis and management of asthma. Ann Allergy Asthma Immunol1997; 78: 427-437.
A. In response, we have the following clarifications to offer:
1. During an asthma exacerbation at home one nebulization of beta 2 sympathomimetics or 2-4 puffs with MDI and spacer every 20 minutes in 1st hour are recommended. The group did not think it was appropriate for the patients to continue further therapy at home because over reliance on nebulizers
at home may prove to. be detrimental. If the response to initial
treatment is poor, the doctor must be contacted immediately.
2. Omitting of inhaled Ipratropium bromide from Fig. 2 was a typographical error, correction for which has been made.
3. The group was quite aware that Aminophylline infusion is no longer amongst the therapies recommended in treatment of acute severe asthma exacerbation. This treatment was suggested by the group where facilities for continuous nebulization of beta 2 sympathomimetics may not be available. Some recent trials do mention usefulness of this modality(l,2).
Meenu Singh,
Sunit Singhi,
Lata Kumar,
Department of Pediatrics,
Postgraduate institute of
Medical Education and Research,
Chandigarh i60 012,
india.
REFERENCES
1.
Ohta K, Nakagome K, Akiyama K, Sano Y, Matsumura Y, Kudo S, et al. Aminophy!line is effective in acute exacerbation of asthma in adults-objective improvements in peak flow, spirogram, arterial blood gas measurements
and lung sounds.Clin Exp Allerg 1996; 1: 32- 37.
2.
Montserrat JM, Barbera JA, Viegas C, Roca J, Rodgrigues RR. Gas exchange response to in- travenous aminophyllline
in patient with a severe exacerbation of asthma. European Resp J 1995; 8: 28-33.
Consensus Guidelines on Management of Childhood Asthma in India:
Role of Ipratropium Bromide in Acute Episode
Q. 1. The corner stone of therapy of acute exacerbation of asthma is the
rapid reversal of the patient's airway obstruction. The sympathomimetics have evolved as the drug of choice because of their rapid onset of action and potency. However, clinical experience shows that not all patients respond as quickly as desired. In seeking ways of producing more expeditious relief, it has been suggested that a .combination of
β2 agonist with other types of bronchodilators may be more efficacious than an individual agent alone(1).
In line with the above mentioned idea the recent consensus protocol suggests institution of nebulized anticholinergics, e.g., ipratropium
bromide as one of the quick relief medications(2). These are to be added
when a patient shows incomplete or poor response to initial therapy with
β2 agonists.
But the consensus guidelines for management of child- hood asthma in India have not mentioned the use of this group of drugs(3).
Inhaled antimuscarinic drugs cause bronchodilation by competing for airway muscarinic receptors with acetylcholine released from parasympathetic nerves. Drugs such as ipratropium
bromide are thought to act predominantly on M3 receptors on airway
smooth muscles, but they may have some additional autoinhibitory action on M2 receptors on cholinergic nerves or on M, receptors on autonomic ganglia(4),
β2 agonists act more in the peripheral airways whereas ipratropium has generalized action throughout the lung(5). Thus, these two drugs when used simultaneously
have
different sites of action. Hence
in cases of non response or partial response to salbutamol alone given initially, combination with ipratropium bromide may be beneficial for early recovery(6). Moreover anticholinergics
have been particularly of use for management of acute attacks in younger children (3-30 months)(7).
Thus we seek clarification regarding the use of anticholinergics
in the emergency management of young asthmatics.
Munni Ray,
Veena Parmar,
Department of Pediatrics,
Government Medical College Hospital,
Chandigarh 160 047, India.
REFERENCES
1.
Me Fadden ER, EL Sanadi N, Strauss L, Galan G, Dixon L, McFadden CB, et al. The influ- ence of paraysmpatholytics on the resolution of acute attacks of asthma. Am J Med 1997; 102: 7-13.
2. New Guidelines for Diagnosis and Management of Asthma. Ann Allergy Asthma Immunol1997; 78: 427-435.
3.
Consensus Guidelines on Management of childhood Asthma in India. Indian Pediatr 1999; 36: 157-165.
4.
Barnes PJ. Muscarinic receptor subtypes in airways. Eur Respir J 1993; 6: 328-331.
5.Partridge M, Saunders K. Site of action of ipratropium bromide and clinical and physi- ological determinants of response in patients with asthma. Thorax 1981; 36: 510-533.
6.
Beck R; Robertson C, Galdes-Sebaldt M, Levison H. Clinical and laboratory observations on combined salbutamol and ipratropium
bromide by inhalation in the treatment of severe acute asthma. J Pediatr 1985; 107: 605- 608.
7.
Stokes GM, Milner AD, Hodges IGC, Henry
RL. Nebulized ipratropium bromide in wheezy infants and children. Eur J Respir Dis. ] 983; 64
(SuppI128): 494-498.
A. The Consensus Group had discussed in de- tail the role of Ipratropium
bromide in treatment of acute exacerbation in the emergency room and had supported its use. A systemic review protocol in the 1998 issue of the Cochrane Library was also consulted in this context(l). The use ofIpratropium bromide in the incomplete/poor responder group was indeed made a part of these recommendations.
However, it got omitted due to typographical error which is regretted. The correct suggest- ed protocol for incomplete poor responders (sub head B) is depicted in Table I.
TABLE 1- The Suggested Protocol for Incomplete! Poor Responders in Emergency' Room Management Protocol for Acute Exacerbation of Childhood Asthma
(B) Incomplete/poor responders
Continue 02, P2 sympathomimetic inhalations every 20 min. Continuous nebulization can also be used under strict monitoring for heart rate and blood potassium levels.
Continue systemic steroids
Add ipratropium bromide nebulization 250 micrograms every 20 min for three doses. May mix in same nebulizer with P2 sympathomimetic
If no response, aminophylline infusion, (0.9 mg! , kg/h) can be tried.
IV 50% MgS04 50 mg/kg/dose infusion in 30 ml normal saline/30 min can be given before transfer to ICU.
Meenu Singh,
Lata Kumar,
Department of Pediatrics,
Postgraduate Institute of
Medical Education and Research,
Chandigarh, 160012, India.
REFERENCE
1.
Plotnick LH, Ducharme FM. Efficacy and safety of combined inhaled cholinergics and beta 2 agonists in the initial managem,ent of acute pediatric asthma. The Cochrane Library. 1998 Issue 2. Update Software, Oxford, UK.
Role of Ketotifen in Asthma
Q. 1. The Consensus Guideline on Management of Childhood Asthma in India (l) do not comment on the role of Ketotifen.
I have found it to be useful in the long term management of children below 5 years of age who have persistent asthma. It is difficult to routinely use inhalers, even with spacers fitted with masks, at this age. Ketotifen is cheap. I would like to know the experts' opinion.
Newton Luiz,
Dhanya Mission Hospital,
Potta P. O. 680 722,
Thrissur Dt,
Kerala.
REFERENCE
1.
Consensus Guidelines on Management of Childhood Asthma in India. Indian Pediatr 1999; 36: 157-165.
A. None of the current recommendations mention Ketotifen in long term management of asthma. However, various authors have tried to see if it has a steroid sparing
effect(I,2). No such effect has been noted. A
multicenter randomized placebo-controlled double-blind study on the efficacy of Ketotifen in infants and young children has not shown any therapeutic advantage of Ketotifen over placebo(l). Our own study done many years ago also showed Sodium Chromoglycate to be better prophylactic agent. Therefore, we do not recommend the use of Ketotifen in our guidelines.
Lata Kumar,
Professor and Head,
Department of Pediatrics.
Post Graduate Institute of
Medical Eudcation and Research,
Chandigarh 160012, India.
REFERENCES
1.
van Asperen PP, McKay KO, Mellis CM, Loh RK, Harth SC, Thong YH, et at. A multicentre randomized placebo-controlled double-blind study on the efficacy of Ketotifen in infants with chronic cough or wheeze. J Pediatr Child Hlth 1992; 28: 442-446.
2.
Canny-OJ, Reisman-J, Levison-H. Does ketotifen have a steroid-sparing effect in childhood asthma? Eur Resp J 1997; 10: 65-70.
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