Monday, August 24, 2015

Management of Viral Induced Wheeze

Inhaled bronchodilators

  • often first-line therapy 
  • effective rescue treatment in symptomatic patients, especially in children with established asthma
  • have not been shown to improve clinical outcomes, decrease the rate of hospital admission, or decrease the duration of hospitalization in children with bronchiolitis

Inhaled hypertonic saline

  • Limited data suggest that HS in combination with a short-acting beta2-agonist may be effective
  • Similar limited findings have been reported for the treatment of bronchiolitis. 
  • The use is based upon the hypothesis that viral infection, particularly with rhinovirus, leads to dehydration of the airway surface liquid and impaired mucus clearance

intermittent high-dose inhaled glucocorticoids

  • if started at the onset of a URI and continued for up to 10 days, may decrease asthma-type symptoms and rescue oral glucocorticoid use in preschool children
  • may be particularly effective in patients with asthma risk factors

Systemic glucocorticoids

  • data are mixed regarding, although overall this approach does not appear to be effective in most patients 

Intermittent leukotriene-receptor antagonists 

  • results are mixed, but the majority of studies do not favor the use 
  • PREEMPT study examined intermittent montelukast compared with placebo in 220 children aged 2-14. Treatment was initiated at the onset of symptoms of a respiratory tract infection and continued for a minimum of a week or until symptoms had disappeared for 48 hours. The montelukast group had fewer unscheduled consultations for asthma and fewer days away from school.
  • A three way comparison between standard treatment, intermittent montelukast, and intermittent nebulised budesonide (the only aerosolised steroid permitted by the FDA in preschool children) in 238 children aged 12-59 months showed minor and equivalent benefits for the two active treatments compared with standard treatment.

Recommendation For treatment 

  • inhaled short-acting beta2-agonist (Grade 2B) such as albuterol via nebulizer (in NS) or metered dose inhaler (MDI) with spacer (table 1).
  • suggest not using inhaled glucocorticoids (Grade 2B).
  • suggest not using an oral glucocorticoid (Grade 2B). One exception is patients with severe acute wheezing symptoms and risk factors for persistent asthma (assessed by positive-modified asthma predictive indices)

Recommendation for prevention

  • intermittent high-dose inhaled glucocorticoids (table 2), begun at the onset of a URI, before wheezing has occurred, and continued for up to 10 days (Grade 2B). Fluticasone propionate 750 mcg inhaled twice daily and budesonide 1 mg nebulized twice daily have both been studied in the prevention of virus-inducing wheezing in preschool children. 
  • suggest not using an oral glucocorticoid at the onset of a URI before wheezing has occurred (Grade 2B). Exceptions include patients with a prior history of a severe virus-induced wheezing exacerbation requiring hospitalization, patients with asthma risk factors who are currently on daily inhaled glucocorticoids for frequent exacerbations, or those who have not responded to high-dose intermittent inhaled glucocorticoids in the past. 
  • recommend daily inhaled glucocorticoids at standard doses in children who continue to experience severe or recurrent episodes of wheezing despite intermittent high-dose inhaled glucocorticoids (Grade 1A). 
  • Intermittent or daily montelukast is an alternative, especially for patients who do not tolerate daily inhaled glucocorticoids.

References;

  1. www.uptodate.com
  2. https://www.epocrates.com/dacc/1404/WheezePreschoolChildrenBMJ1404
  3. http://www.aacijournal.com/content/10/1/21
  4. http://pediatrics.aappublications.org/content/129/2/e285.full

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