Treatment for Pediatric bronchospasm

[Brenna's Dad]

I'm not sure if this in the literature or not (probably) and I haven't really studied it yet, but...

If you have a 10kg kid with bronchospasm, what would you treatment be. I'm imagining, that in the pediatric population (and perhaps adults as well) that Epinephrine is the drug of choice. A cardiac arrest dose is 10mcg/kg, so knowing that Epi has greater efficacy for B2 receptors at lower doses, what kind of dose would you administer to the kid in the above situation?

I'm thinking 10-20 mcg and titrate.

[canoehead, BSN, RN]

If a cardiac arrest dose is 10, why would you go with 10-20?

[Tenesma]

brenna's dad meant 10-20 mcg instead of 100mcg (as would be the dose for 10mcg/kg)...

anyway, brenna's dad... i often draw up a syringe with 1mcg/cc and give 1 to 2 mcg at a time if it is severe, if it is moderate i will put them on a low dose epinephrine drip (0.5mcg/min) --- everybody freaks out in the recovery room, but if the bronchospasm clears just turn it off, at a low dose you really don't see that much hemodynamic effects...

[Brenna's Dad]

So the dose you are using then is really 1/100 of a cardiac arrest dose? 1-2 mcg, not 1-2 mcg/kg?

[Tenesma]

sorry i fixed my post... i meant 1mcg/cc so i only give 1 or 2mcg at a time total -- so about 1/100 of a cardiac dose... you don't need very much to help with bronchospasm

[Law of Fives]

There are other bronchodilators available that are a better choice in terms of effectiveness and side effect profile. With drugs such as albuterol or racemic epinephrine available, why would you start them on an iv drip of epi.?

Just curious.

[Tenesma]

law of fives:

there are different types of bronchospasm: there is reactive airway that responds nicely to aerosolized meds (albuterol, etc..), and then there is total bronchospasm where the lungs snap shut and you can't ventilate worth squat.... and if you can't ventilate, then you definitely can't benefit from aerosolized meds - hence the need for something effective via IV: epinephrine.

[pasgasser]

Tenesma is correct in that epinephrine is one of the most effective if not the most effective way to treat severe bronchospasm and is usually more readily available than isoproterenol. Ephedrine is a good bronchodilator via its indirect effect of produing endogenous catacolamines. IV meds that are usually readily available which are also very good are propofol, ketamine (indirect effect), and IV lidocaine. IV lidocaine is usually my first line treatment. Etomidate and barbiturates do not have bronchodilating properties. Also all VA's, yes even desflurane, are bronchodilators and deepening of the anesthetic often will treat bronchspasm. If you are using halothane do not give the pt epinephrine. Prevention is alot better than treatment and giving at risk pts an anticholinergic pre-op will save you trouble.

Note: desflurane only works and approx. 4 mac and does cause airway irritation when dose is decreased so it is not a good choice in pt's. with reactive airway disease.

[Law of Fives]

Originally posted by Tenesma

different types of bronchospasm

I did not know that.

Originally posted by Tenesma

and then there is total bronchospasm where the lungs snap shut

I wonder what the pathophysiology associated with 'total' bronchospasm is in regard to your proposed difference between it and 'reactive' bronchospasm. I guess I understand the reactive variety, but I was under the impression that on the molecular bronchospasm is bronchospasm, and by that logic should respond to a Beta 2 agonist. I understand your point of decreased distribution due to severe bronchospasm therefore necesitating IV therapy, but to consider IV therapy first line just seems a little foreign to me. But, I'm not a CRNA, just a CRNA wanna-be at this point.

Originally posted by pasgasser

and giving at risk pts an anticholinergic pre-op will save you trouble.

Care to discuss the mechanism of action associated here? Thanks

[Tenesma]

exact same mechanism of action... the description of "total" is mine entirely!!! bronchospasm is bronchospasm is bronchospasm... the one thing that is important in pedi is how quickly they can desaturate and they don't have the same reserve. So if a 10kg baby goes into bronchospasm and you can't ventilate you aren't going to waste much time give dose after dose of albuterol... it is interesting how things that we do in the OR can sound so foreign and strange to people outside of the OR :)

[DustinRN]

I was just wondering why their aren't any B2 selective agents in IV form? Would it just cause smooth muscle relaxation out the ying yang?

[Tenesma]

I was just wondering why their aren't any B2 selective agents in IV form? Would it just cause smooth muscle relaxation out the ying yang?

low dose epinephrine is actually B2 selective to a certain degree