What is the recommended treatment for chest phlegm in a child post-intubation using Atrovent (ipratropium bromide)?

Ipratropium Bromide (Atrovent) for Post-Intubation Chest Phlegm in Children

Ipratropium bromide (Atrovent) can be effectively used at a dose of 0.5 mg nebulized every 6 hours for managing chest phlegm in children post-intubation, though there is limited specific guidance for this indication. 1

Dosing Recommendations

The appropriate dosage of ipratropium bromide varies by age:

• Children over 2-3 years: 250 micrograms via nebulization 2
• Children under 2-3 years: Maximum 125 micrograms via nebulized solution 2
• Pre-term infants: Maximum 20 micrograms (doses exceeding this may produce side effects) 2

Administration Methods

Two effective delivery methods have been demonstrated:

1. Conventional nebulization: Traditional method used in hospital settings
2. Metered-dose aerosol with spacer and mask: Equally effective as nebulization, more convenient, requires less time and equipment, and is well-accepted by young patients 3

Efficacy for Post-Intubation Phlegm

While specific guidelines for post-intubation phlegm management are limited, evidence suggests:

• Ipratropium bromide is effective in approximately 40% of children with recurrent airways obstruction 2
• It can be particularly useful in children under 18 months when beta-2 stimulants are rarely effective 2
• In ventilated infants with bronchopulmonary dysplasia, ipratropium bromide (particularly at higher doses of 175 micrograms) demonstrated significant improvement in respiratory system resistance 4

Combination Therapy

• The combination of ipratropium bromide with beta-2 agonists (such as salbutamol) provides enhanced bronchodilation compared to either agent alone 4
• For optimal results in managing post-intubation secretions, consider combination therapy with:
  • Ipratropium bromide: 0.5 mg nebulized every 6 hours
  • Salbutamol/Albuterol: 5-10 mg every 15-30 minutes as needed 1

Airway Clearance Considerations

The British Thoracic Society notes that:

• There is insufficient evidence to recommend chest physiotherapy as standard care for airway clearance 5
• However, cough-assist techniques should be considered for patients with neuromuscular disease to prevent respiratory failure 5
• Routine instillation of isotonic saline prior to endotracheal suctioning is not recommended 5

Important Caveats

1. Monitoring: Meticulous attention to respiratory parameters is essential when managing post-intubation patients
2. Patient positioning: Maintain head of bed elevated to 30-45° unless contraindicated 5
3. Age-appropriate dosing: Be particularly cautious with dosing in very young children and premature infants 2
4. Individualized assessment: Response to ipratropium varies among children, with approximately 40% showing significant benefit 2

While there are no specific guidelines addressing ipratropium bromide for post-intubation phlegm in children, the evidence supports its use as an effective anticholinergic bronchodilator that can help manage secretions and improve respiratory mechanics in this population.