Controversy: RSV patients and bronchodilators
Controversy: RSV patients and bronchodilators
The use of bronchodilators such as albuterol is controversial because most respiratory syncytial virus (RSV) patients do not respond to them, says Jennifer Dearman, RN, BN, charge nurse at the pediatric ED at Loma Linda (CA) University Medical Center and Children’s Hospital.
Specifically, albuterol is not widely supported as a medication that has positive effects, Dearman explains. Still, bronchodilators are still the first line of treatment in the ED.
"It is appropriate to give them a trial when a child comes in as a first-time wheezer to assess their response," she says. It is worth a trial, because staff are not sure if the problem is RSV when the child first presents to the ED with wheezing and hypoxia.
RSV testing has a one-half hour turnaround time, notes Dearman. "In that time, a bronchodilator treatment may be initiated," she says. If hospitals are giving continuous bronchodilator treatments without effect, that is inappropriate. "But a trial in the ED is not inappropriate."
Minority responds to albuterol
Only about 30% of children with RSV will respond to albuterol, says Carol Ledwith, MD, FAAP, an attending physician in the ED at the Children’s Hospital ED in Denver. "So it’s perfectly reasonable to try, but it’s not appropriate to keep giving kids albuterol unless they show a clearly documented clinical response."
If after one or two ß2-agonist nebulizer treatments, the child’s pulse oximetry reading, respiratory rate, and other definable parameters on their exam do not improve, the albuterol should be discontinued, stresses Ledwith.
RSV is a virus that produces symptoms similar to asthma, but the diseases are not the same. "Bronchiolitis was treated just like asthma. So any wheezing child used to be given ß2-agonist nebulizers, which is the standard nebulizer used for asthma," says Ledwith. "The problem is that most asthma responds to albuterol inhalers, but bronchiolitis is a different disease. Not all of those kids have a component of reactive bronchospasm."
Asthma requires management with repeat nebulizers and steroids, but that’s not appropriate therapy for bronchiolitis. "It’s not the same disease, and management is not the same," stresses Ledwith. "RSV is an acute viral illness, and only time will tell if that patient will go on to be labeled an asthmatic."
It is reasonable to be more suspicious of asthma than bronchiolitis if there is a strong family history; if they are highly reactive to ß2-agonist nebulizers; if they have a personal history of eczema or atopy; and if wheezing is a much greater component than crackling, Ledwith says.
There is no indication whatsoever for albuterol syrup, Ledwith emphasizes. "It has fallen out of favor because it causes tachycardia without having any benefits."
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