all right so let's talk about respiratory stuff for a few minutes so we've got a 14 year old who comes in with severe shortness of breath has a history of asthma no relief from home nebs ems went ahead and gave her some albuterol and epitropium twice there's her vital signs she's a little tachycardic a little deceptic sats are right there on the borderline 93 in room air she's got a lot of wheezing a lot of accessory muscle use so what are you going to do next she's already had a couple of albuterols she's already had some epitrophium as well what's going to be our next step we're going to give her some more albuterol please don't it's not going to work so steroids what else magnesium yes and maybe a different beta agonist like epinephrine so we've got several other options out there but if they've had five or six albuterol nebs and it's not fixing them please stop and do something else because are gonna do is get their heart rate up even more and make them more anxious and probably not fix them yes we'll come back to that yes so with asthma a chronic obstructive reversible airway disease most people that have asthma have some type of immunological trigger they get exposed to a pollen dander something that triggers the immune response now also a big trigger especially this time of the year is viral infections it causes the reaction but it's not truly immunological but what happens is we activate the immune response we release good old histamine histamine causes mucus production and airway narrowing that's what happens with asthma so our whole focus is trying to reverse the airway narrowing and suppress that immune response we're with copd most of our people that have copd have it from chronic smoking occasionally we'll run the people that actually have it from either secondary exposure or from occupational exposure but most people chronic smoking your typica emphysema patient this person is the classic barrel chest appearance they have caused significant alteration of their lung compliance so now they have great distinction but they're alveoli don't come back to normal so they have that classic barrel appearance where your chronic bronchitis patient that's your chronic productive cough this person produces all that thick sputum and they're chronically trying to get all that fixed sputum up it is a subset of these patients that i have to worry about being co2 retainers because most of us remember from initial nursing or medical education they're like oh don't give more than two liters you'll kill them not really the case for most people but it's a small group of these chronic bronchitis patients we have to worry about but they're going to have that respiratory distress that dysentemy at rest may have some wheezes a lot of accessory muscle use so just kind of give you this table just kind of help you differentiate what we see with some of these but barrel chest is classic for emphysema do i hear wheezing or not if i don't hear wheezing do i hear good lung sounds occasionally you don't hear wheezing because they're not moving any air they're so tight so croup an acute viral infection usually causes uh problems this time of the year most we think about this with young kids but we also can get adults that get crouped they get the inflammation the airways it causes that narrowing gives them that classic strider so that barky cough that we'll sometimes see but usually it's a viral infection low-grade fever and most these kids don't look toxic they look sick but they don't look toxic and i'm really concerned is when they're laying there doing nothing and they have strider if they're running around the room strider us that's probably okay but when they're laying there doing nothing in their striders that's when i really get concerned so our drugs so anticholinergics or antimuscarinics most these are only fda approved for treatment with copd but we use them in asthma as well off label anticholinergy is going to cause a couple things to happen they're going to reduce mucus production they do have some anti-inflammatory properties and they do have some muscle relaxation properties so they're kind of like a beta agonist but not truly a beta agonist they work in a different platform but they're going to give us several benefits there and usually used in combination with a beta agonist typically anticholinergics are first line drugs for initial copd management depending on the severity of their disease but anticholinergic is going to work a couple of ways and give us a couple of benefits so asthma copd maintenance we may use them in acute exacerbations they do have some synergistic effects luckily they're localized effects so not too many systemic effects but if somebody has really bad bph or really bad glaucoma that's the person i might be more considerate of not using anticholinergic for the most part it's localized affects the lung tissue but in large doses could cause systemic effects our beta agonists are a mainstay for asthma management and acute exacerbation management as well the big thing about beta agonas is they're going to give us sometimes localized effect but sometimes systemic effects and most these are beta-2 agonists so they're going to prefer beta-2 over beta-1 but they still give us some beta-1 effects and some people a little bit more sensitive than others when we talk about beta effects so an initial patient comes in with a lot of respiratory distress a beta agona should be our goal but if they've already had several doses of a beta agonist we need to think about other options but these are going to have a little bit also anti-inflammatory properties as well they do tend to help reduce that mucus production they do kind of help smooth out those inflammatory processes as well but they're not always going to be best for every patient by themselves so epinephrine is a really good bait agonist we don't always think about it with asthma but definitely that patient who's had multiple doses of albuterol or leave albuterol and they're not better then we should go to epinephrine there's really good evidence and this is in the guidelines that if they've had multiple doses of beta agonists let's think about epinephrine next that could be inhaled or that could be an injection in the thigh works just as well probably iv is our least uh used and definitely only in severe cases but just keep in mind it is a pure alpha and beta agonist that's going to get everything but definitely refractory asthma epi is a good option so prima team missed inhaler that was available and disappeared it's now back it's available over the counter and you may find people that have asthma that they're treating themselves with primate mist it is epinephrine it went away because of its cfc but it is now back but definitely that patient is not getting better with one treatment think about going to something else an epi is a really good option we nebulize it or we give it to him i am so racemic epi so racemic epi's a half of that epinephrine it's part of the isomer for years we thought racinegappy was a really good agent for croup for stridor and it still is there has been a couple studies that show that it's probably no better than epinephrine the thought is initially that racemic it's half of the isomers so it's a little lighter in weight so racemic may stay in the upper airways more than epinephrine which is heavier and goes to the deeper airways so if you have racemic available it's great to use for strider or croup if you don't have it available you can easily nebulize epinephrine as well and get the same benefit but appi may give you a bit more of that beta effect it may give you some more of that other systemic effects that you don't always see with receiving the big thing here is if we're giving somebody racemic we need to watch them for several hours because let's see what happens when the medication wears off if that kid gets a receivement they do great but in two to three hours the croup comes back that kid can't go home that kid's gonna have to come in used to think it was this rebound effect it's not really rebound it's just the drug wears off it's half-life exhaust and the drug wears off so let's watch them asthma nephron that's available over the counter is racemic epinephrine so if you hear somebody taking it they're using to treat themselves probably for their asthma as well it helps some but not as good as say the epinephrine or the albuterol itself albuterol has been our beta-2 atoms of choice for years albuterol is a really good beta agonist it's going to help several things there in the bronchial tree as i mentioned it is beta 2 selective but it still has some beta 1 properties leave albuterol is simply a different version of albuterol thought to have less beta 1 effects it is more expensive and in some patients that are truly sensitive to beta-2 agonists leave albuterol might be a good option most time we would go ahead and do that nebulization there in the ed with the coven 19 pandemic initially we kind of stopped doing those for most people the middle dose inhalers are just as effective and they probably don't waste as much of the drug so a lot of us have gone just to using mdis in the ed versus the nebulizers but definitely if people aren't getting better with other things we can try those the mdis are great but people have to be able to do the right thing in the right order they have to squeeze and inhale at the right time and some people don't have really good psychomotor skills they take some education there to get that to work and i mentioned the leave albuterol a little bit more expensive but definitely is an option if someone is really sensitive but both are equally effective at treating bronchospasms reducing airway inflammation and airway narrowing those are all sabbas short acting beta agonists they're going to give us benefit for a couple hours for the most part we talk about those being rescue drugs and we look at the asthma guidelines people should always have access to one of these but it's not their main stay of therapy for chronic management that would be our labas our long-acting beta agonists mostly are going to have a duration about 12 to 24 hours these long-acting beta agons are really important for maintenance therapy in asthma patients it should always be combined with an inhaled corticosteroid they have a black box warning for that warning that we know that labas by themselves actually may increase mortality but if we combine it with an ics that doesn't happen and anybody who has more than just intermittent asthma should always be on a laba and there's discussions from the literature about we should probably go and initiate this or at least initiate inter inhale corticosteroid therapy in the ed because primary care is not always easy to get into or hey they'll see them in three weeks that's not always the best option either but it's really important for people to understand that labs are maintenance and they can use it during their acute exacerbation but it may not work for a couple hours they need to have access to a saba that's usually their albuterol or their leave albuterol all these drugs can cause some systemic effects especially in large doses if they've had six of their albuterol treatments they're probably gonna have some systemic effects they're gonna be anxious they're gonna probably have some tachycardia probably some palpitations they're not gonna be really happy that's just the beta effects but definitely educate people some people especially they have significant coronary artery disease might be a little sensitive to that tachycardia and they have some demand things that may happen but for the most part these are well tolerated just have to educate people about them hey this is what the beta agnes may do to you so i'm going to give you this table of here showing these and there's several others out there combination therapy we know is really helpful because if they do one inhaler versus two you tend to have better compliance but especially for asthma laba should always be used with an inhaled corticosteroid our methylxanthines theoflin haven't seen that use in a long time it's not commonly used anymore like we used to mostly used with copd anyway but if someone still is on theophyll and they've got really significant pulmonary disease it has some toxic effects just from chronic use so with their own diaphragm they've got really bad lung disease so magnesium so magnesium is a smooth muscle relaxer it works for several things we use it for pre-term labor for that reason we also use it for other things but magnesium is going to work in a different pathway to relax the bronchi so typically adults we're going to give 2 grams iv piggy back over 10 minutes that's all they need and that usually makes a difference children should be weight based 50 per kilo but in that person who's refractory asthma we've given albuterol we've given hippotropium we may have even given epinephrine let's think about some magnesium magnesium is going to work in a different pathway but also give us some smooth muscle relaxation and that may be enough to break this refractory cycle don't give it too fast because it vasodilates things drops to blood pressure makes them feel real flushed and luckily two grams is not a lot compared to when we get to ob we talk about six grams and they really hate us thin but over 10 or 15 minutes usually does fine with that but if they've not gotten a lot better with other things think about magnesium we should do it sooner versus later if they've already had a couple treatments at home go ahead and get the mag going it really can't help yes so question was do we need to watch it for several hours not necessarily for the magnesium itself obviously we should watch them for several hours post all their treatments but not specifically for the magnesium yes usually it's magnesium sulfate that's what usually comes in the parental formulation and some of us may have it pre-mixed or pharmacy does it for us but usually it's max sulfate so are corticosteroids for years we talked about things like systemic corticosteroids for inflammatory conditions plays a big role with asthma also with copd but one of the important things here is also thinking about inhaled steroids so if i get the corticosteroids right where they need to be we tend to have more more effect and less side effects so we're going to reduce the inflammatory response we're going to stop that histamine release we're going to calm down some of that inflammation and that mucus production anybody who has more than pers then intermediate asthma should be on an inhaled corticosteroid and probably for most of us we should start getting inhaled corticosteroids in the ed during acute asthma attack there's really no benefit of giving iv over oral or inhaled for the most part so if you're given that albuterol treatment that epi treatment go ahead and give an inhale quirk a steroid as well put it where it needs to work right here in the lung tissue so we've got several options here if it's a short course of say five to seven days they don't need a taper corticosteroid tapers are only important it's been over two weeks of therapy and hopefully we're not having to do that they need close follow-up care anyway but think about the role we can give them some steroids give them some prednisone to take by mouth that's fine iv steroids sure if we can't get them to take stuff by mouth but it's not necessary but think about the role of inhaled corticosteroids give them some bendessenide or whatever you have available that tends to help if all else fails you can nebulize dexamethasone you can actually drink it too it doesn't taste very good kids never like the taste of any of them but you can always nebulize decks if you need to and that will help reduce some of that inflammation as well inhaled quickest steroid use long-term for the most part is safe there are a couple studies that show that in kids it may slow their stature but by the time they reach adulthood they will reach their normal expected stature so it does cause a little bit of growth stunning but they do regain that for the most part inhale quirky steroids don't affect the hpa axis but they could unlike where oral or systemic steroids definitely are going to cause some hpa axis inhibition but any patient who has more than intermediate asthma should always be an ics and that patient who we see in the ed who doesn't have proper therapy if you can prescribe them an inhaled cortical steroid please do that is really going to help control and hopefully limit or prevent their exacerbations and try to get them in to see somebody if you don't have that available so kind of gave this table here different potencies for the different corticosteroids are out there hydrocortisone which won't use a lot for asthma is our baseline prototype when we compare everything back to hydrocortisone hydrocortisone is the most like cortisol but some of these are really potent some of these are not as potent but we have different levels low medium and even high intensity uh inhaled corticosteroids in that case hopefully we've got some of this mandate there like a pulmonologist or an asthma specialist to manage those patients but definitely if they're not on one and they can get one please prescribe them in a hell cortical steroid from the e.d we may even start the therapy there oftentimes if i can they can't afford it i'm just going to give it to them in the e.d and they can take it home with them we'll deal with the cost later i don't care but if they have low resources that can at least give them an inhaler in the er now they have it to use so they get follow-up care same with our copd patients almost all these patients would benefit from being on an inhaled cortical steroid again we're trying to reduce that inflammatory response and there's several options out there you can get ics combined with the laba or by itself there are some newer longer acting drugs out there that we can use as well anti-muscarinics also play a big role with copd management smoking cessation is also really important it does not reverse the damage that's done but it does reverse and remove that trigger because if they're not smoking they don't have the exposure to that allergen that triggers the immune response as much and patients will argue all day long i've been smoking for 30 years when i quit well if you might make your next 10 years a little better off but medication therapy is really important for all these patients but unfortunately you can see some they're not very cheap 400 300 good rx may come into play hopefully you have some other resource program for patients that they don't have financial resources to afford these medications they're really important for improving their quality of life and suppressing their disease process inhaled corticosteroids the big thing i usually worry about there is it can cause an oral functional infection because it does suppress those areas so typically do recommend that patients that are using a helicosteroid just rinse their mouth out afterwards and spit it out that does reduce the risk of them getting either oral or esophageal canadal infections because most of that in healthcare steroid they swallow it we want to get as much of the lungs as possible they end up swallowing a lot of it and i've already covered most these things suppression does happen but not as common most these patients do very well and tolerate these very well and are really important for persistent asthma or for chronic copd our monoclonal antibodies occasionally run into patients that are on these so these are some of our newer mab drugs anytime you see mab that's a monoclonal antibody and these are to go in and try to suppress the immune response as well we're not giving these in the ed but i definitely encounter people that have had significant reactions to some of these when are getting their infusions so either go in and get an infusion or injection and then as to suppress the immune response and usually works really well but if you're encountering a patient who's on one of these agents they have significant refractory asthma and these drugs work they're going to either work on this inosilophilic suppression or another part of the immune response but that just tells you this person has significant persistent asthma and they've had to go up to the step five or step six approach for their asthma but if they you encounter them they're having that reaction to just like any other anaphylaxis we'll talk about this more in a little bit but it's epinephrine epi is our drug of choice for anaphylaxis these are not cheap as you can see uh for one of them and thirty eight thousand dollars a year but if someone has a lot of asthma exacerbation these can be good options and you may see people that are on these and just recognize they have severe asthma if they're on these agents so this is a table kind of goes through the stepwise approach and some of the new guidelines that just came out the vagina guidelines they've kind of revised some of this so you may see start seeing that come in the literature but intermittent asthma so they have only a few symptoms only a few attacks those patients probably would benefit from at least having just a saba access some people may go and put them on a hell quarter steroid but anybody that has persistent asthma should always be on an ics and when you think about needing access to a saba and also a laba as well and as they move up to severity based on the number of symptoms the number of exacerbations the more aggressive their therapy is going to be but these patients should always have access to a saba and ideally an ics as well so here's the stepwise approach just kind of give you an idea most of us aren't managers chronically in our practice but definitely if you're seeing somebody who's on a high-dose ics with a laba and an oral curve steroid that's step six they've got significant disease if they're on one of those mab therapies that's significant disease but just kind of give you the guidelines that are out there to what we're using and what their current recommendations are so if you encounter that patient you kind of have an idea where they're at because sometimes they're great historians and sometimes they're not so what can they tell us what can the drugs tell us about their disease process and then our guidelines for treating copd most is going to be based on pulmonary function tests so usually followed by either primary or pulmonology but just kind of get an idea of where they're at you know they may be on that ics with a saba anticholinergics or the antimuscarinics are usually their first line but you may start seeing them get up to where they're actually having a lab of use or other drugs and of course when they get up to needing o2 they've got significant disease and really there is just trying to improve their quality of life we recommend pulmonary rehab trying to improve their quality of life through either doing purslant breathing diaphragmatic breathing and all these therapies that are out there just kind of have an idea what drugs are owned kind of guide you to how severe their disease is then our antihistamines so we have our first and our second generation antihistamines play a significant role with things like allergic rhinitis seasonal allergies several these are now over the counter there's only a few left that aren't from either group our first generation drugs are going to get all the receptors intended across the blood-brain barrier so your first generation drugs tend to cause some drowsiness that's why different hydramine is the kindergarten and most over-the-counter sleep aids all these antihistamines are also anticholinergics so especially first generation may cause that dry mouth urinary retention constipation that we sometimes run into especially they take them a lot they're taking diving hydramine every night to sleep they probably wake up that dry mouth a little bit of urinary tension constipation over time our second generation drugs those a little bit more selective those tend not to cross the blood-brain barrier so they kind of give us a little bit better localized treatment without a lot of systemic disease and i added in there because uh citrazine is now available in iv formulation that just came out a few months ago i don't think that made it to your print but we now can give either diphenhydramine iv or certain iv as well so if someone truly is allergic to diphenhydramine that is an option now for treating them i've encountered a couple people actually just one two weeks ago that swore she was allergic to diphenhydramine i gave her some hydroxyzine and she did fine but she was having a large reaction but you do have a couple options now for this but just keep in mind first generation work but they're going to give you some drowsiness some sleepiness second generation not as bad but these should be your first sign things for seasonal allergies allergic rhinitis going to help with those symptomatology dry those up but also play a role with some other things as well these should not be used in treating asthma because they do have a histamine component but these don't have a benefit tolerance can happen if they use it chronically so that person who was taking 25 benadryl for sleep now has to take 50 or 75 the longer you use it like most everything else your body does develop some tolerance to it for the most part these drugs are very well tolerated first generation more concerning and they're on the beers list and we'll come back to the beers list in a few moments or later this morning and talk about it