[VickyRN]

Just curious about the fine distinguishing points about these three nebs used in pediatric acute airway emergencies.

I know that racemic epinephrine is used for upper airway (croup, stridor), trachealmalacia, or sometimes for BPD.

Albuterol - lower airway, bronchospasms, asthmatic exacerbations.

Xopenex - similar to albuterol, except less cardiotoxic. Not for young children. Used in children 12 and over.

Thanks for any light you can shed..

[janfrn]

Sorry for the lag in responding. I've been busy, you know...

In Canada we don't use Xopenex as yet, but I can tell you a few things.

Our first line is usually racemic epi. It is used, as you say, for croup, stridor, etc, but it also has a bronchodilatory effect through relaxation of smooth muscle so can also be used for asthma or bronchospasm from whatever source. It has a rapid onset of effect, from 1-5 minutes, but a shorter duration of action, only 1-3 hours. Many of our airway issues in our PICU are related to intubation, so we often have racemic ready and waiting when we extubate. (We also give dexamethasone pre and post in kids we expect to give us trouble.)

Albuterol has a fairly rapid onset of effect, about 5 minutes and a duration of action of 3-6 hours. We might use albuterol and racemic in conjunction, alternating between the two in RSV or adenovirus, although the evidence for using either in these kids is weak.

Levalbuterol has a much longer onset of effect than either of the others, 10-17 minutes, but a much longer duration of action, 5-8 hours. It would not be the drug of choice for a rapidly evolving upper or lower airway obstruction but would be a good choice for maintenance. Once you've broken the status epilepticus episode or resolved the acute bronchospasm and the time between doses of bronchodilator increases, this would be the time to switch. It can be used in children over 6 years of age, but is associated with slightly higher side effect rates ( headache, otitis media and fever in kids 6-11) and a lower dose is recommended.

Side effects for all of these are relatively similar. Tachycardia, hypertension and tremulousness are most common across the board. The choice of drug will also have to be tempered by the child's underlying issues, and potential drug interactions recognized. Concomitant use with beta blockers can cause a severe increase in bronchospasm. Digoxin levels will probably be significantly higher. Hypokalemia and ECG changes are worse when diuretics are in the mix.

Does that dot your "I's"?

[AliRae]

Once again, Jan for the win.

Originally Posted by janfrn

...once you've broken the status epilepticus episode...

But did you mean asthmaticus, or am i missing something here?!

And as far as I know levalbuterol is the same as Xopenex, no?

[janfrn]

Originally Posted by AliRae

But did you mean asthmaticus, or am i missing something here?!

Umm, yeah. That's what I meant. Don't know how my fingers came up with that.

Originally Posted by AliRae

And as far as I know levalbuterol is the same as Xopenex, no?

Yeah. In Canada we tend to use the generic names a lot more than the patent names. (And our patent names are different sometimes just to add to the confusion.) At least we old pharm techs do! I wish we would move to ONLY generic names so there would be fewer mixups. Just look at Celebrex/Celexa/Celestone/Cellcept or Ara-C/Aralast/Aralen/Aranelle/Aranesp. Another one of my soapboxes. Climbing down now.

[AliRae]

Originally Posted by janfrn

Another one of my soapboxes. Climbing down now.

*sigh* and I'm about to head out to Africa where I have NO idea whose names they'll be using. I guess my little drug book written by our very own PharmD of our children's hospital won't do me much good...

Originally Posted by janfrn

Umm, yeah. That's what I meant. Don't know how my fingers came up with that.

Tee hee. I was just being a brat pointing that out.

[VickyRN]

Thank you so much, Jan! This is very helpful!

[janfrn]

Originally Posted by AliRae

*sigh* and I'm about to head out to Africa where I have NO idea whose names they'll be using. I guess my little drug book written by our very own PharmD of our children's hospital won't do me much good...

Go with the generic. It should be the same everywhere. Norepinephrine will be norepinephrine. I notice that when our foreign fellows write notes or orders, they use generic names and although sometimes the spelling might be slightly different it's easily recognisable. The people I know who have done charitable mission nursing didn't find it that bad. But I don't know if the groups took their own stock with them.

[janfrn]

Originally Posted by VickyRN

Thank you so much, Jan! This is very helpful!

Glad as always to help out.