From the Guidelines
For a wheezing inpatient already on DuoNebs, steroids, antibiotics, high-flow oxygen, and incentive spirometry, consider adding intravenous magnesium sulfate as an adjunctive treatment if the patient is unresponsive to initial treatments, as it may help in severe exacerbations. According to the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma 1, intravenous magnesium sulfate can be considered in severe exacerbations if patients are unresponsive to initial treatments. The patient's current treatment regimen includes DuoNebs, which contains ipratropium bromide, but as noted in the guidelines, inhaled ipratropium bromide does not provide additional benefit after a patient is hospitalized for a severe exacerbation 1.
Key considerations for further treatment include:
- Repeated lung function measures (FEV1 or PEF) at 1 hour and beyond to assess the need for hospitalization 1
- Pulse oximetry for patients in severe distress or with FEV1 or PEF <40% predicted 1
- Signs and symptoms scores at 1 hour after initial treatments to predict the need for hospitalization 1
- The presence of drowsiness as a predictor of impending respiratory failure, indicating the need for immediate transfer to a facility equipped to offer ventilatory support 1
It is essential to review the patient's treatment plan and consider adjustments as needed to prevent relapse of the exacerbation and recurrence of another exacerbation, including referral to follow-up asthma care, review of inhaler technique, and consideration of initiating inhaled corticosteroids (ICS) 1. Treatments not recommended in the emergency care or hospital setting, such as methylxanthines, antibiotics (except for comorbid conditions), aggressive hydration, chest physical therapy, mucolytics, or sedation, should be avoided 1.
From the Research
Current Treatment
The patient is currently on:
- Duonebs (ipratropium bromide and albuterol sulfate)
- Steroids
- Antibiotics (Abx)
- High flow oxygen
- Incentive spirometry
Potential Next Steps
Based on the provided studies, potential next steps for treatment could include:
- Continuing or adjusting the current treatment regimen, as studies have shown the effectiveness of combination therapy with ipratropium bromide and albuterol sulfate 2
- Monitoring lung volumes and airway resistance, as air trapping has been shown to correlate with increased frequency of albuterol use and severity of wheeze in persistent asthma 3
- Implementing a standardized management pathway to improve timeliness of β-agonist and corticosteroid administration, as this has been shown to improve outcomes in patients with acute wheezing 4
- Considering the prophylactic use of albuterol spray to reduce the incidence of wheezing and recurrent cough, particularly in patients with COPD under general anesthesia 5
Key Findings
- Combination therapy with ipratropium bromide and albuterol sulfate has been shown to be effective in improving lung function and reducing symptoms in patients with COPD and asthma 6, 2
- Air trapping is a significant factor in persistent asthma, and lung volume measurements can help identify patients with air trapping 3
- Standardized management pathways can improve timeliness of β-agonist and corticosteroid administration, leading to improved outcomes in patients with acute wheezing 4
- Prophylactic use of albuterol spray can reduce the incidence of wheezing and recurrent cough in patients with COPD under general anesthesia 5