# Atrovent for Pediatrics



## Tigger (Aug 22, 2015)

Had a pretty good asthma exacerbation today, 11yo female with global inspiratory and expiratory wheezing in all fields. Albuterol rescue inhaler used twice prior to arrival and we provided 2 additional nebulized albuterol treatments along with 100mg of Sol-Medrol. The albuterol had zero effect on lung sounds or the patient's work of breathing (which oddly was not particularly great). Generally in this scenario I would think a duoneb would be the next step to try and alleviate the bronchospasm. 

However, both protocols that I work under do not allow for Atrovent use in patients 13 years or younger. I can find nothing to support this, but did find a half decent study showing some benefit in using it. So what gives? Are we just behind?


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## DesertMedic66 (Aug 22, 2015)

In medic school our pharmacology instructor told us not to use it in pediatrics, however our protocols allow us to use .5mg.


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## Tigger (Aug 22, 2015)

DesertMedic66 said:


> In medic school our pharmacology instructor told us not to use it in pediatrics, however our protocols allow us to use .5mg.


Did he or she say why? I see lots of places do not use it for pediatrics, but no justification.


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## DesertMedic66 (Aug 22, 2015)

I'm honestly not sure anymore. I may see him on Monday so I'll ask if I get the chance.


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## Carlos Danger (Aug 22, 2015)

"Safety and effectiveness in the pediatric population below the age of 12 have not been established." 

Ipratroprium is not FDA approved for peds. So despite several studies (I found references to a handful in a 5-minute Google search) proving its utility, the manufacturer probably never paid to jump through all the hoops to get it approved for peds, and so the wizards at the FDA have not seen fit to give us permission to use it.

I don't know how much it helps anyway, but if I thought it _would_ help in a given situation, I would use it. We use drugs for off-label uses all day long.


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## LACoGurneyjockey (Aug 22, 2015)

We can give atrovent with albuterol for adults and peds, 500mcg across the board, with 2 repeats of atrovent every 20 minutes.


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## teedubbyaw (Aug 22, 2015)

Ours is the same for adults...0.5mg neb solution. I've not heard of it not being used for pedi's.


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## ERDoc (Aug 22, 2015)

I use it all the time for peds.  Our PICU docs have us do 3 duonebs for kids that are going to end up in the unit.  As for why it is not FDA approved for peds is probably like Remi said.  There is no money to be made by running the necessary trials to get FDA approval.


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## Tigger (Aug 22, 2015)

Duly noted, perhaps a call in will deal with that next time.


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## Household6 (Aug 22, 2015)

We use terbutaline for peds 0.01mg/kg SC but only if the ped is in RA.. 

Once loaded, we use Atrovent (0.5) *only with the first dose* of Albuterol  for a pt in mod/severe resp distress..


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## Smitty213 (Aug 23, 2015)

Tigger said:


> perhaps a call in will deal with that next time.



I've done it once for a male pt, about the same age. No change after one 0.5mg Albuterol neb, so I called in and got the go ahead without really any issue; it certainly accomplished more than the Albuterol alone.


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## CANMAN (Aug 23, 2015)

Tigger said:


> Had a pretty good asthma exacerbation today, 11yo female with global inspiratory and expiratory wheezing in all fields. Albuterol rescue inhaler used twice prior to arrival and we provided 2 additional nebulized albuterol treatments along with 100mg of Sol-Medrol. The albuterol had zero effect on lung sounds or the patient's work of breathing (which oddly was not particularly great). Generally in this scenario I would think a duoneb would be the next step to try and alleviate the bronchospasm.
> 
> However, both protocols that I work under do not allow for Atrovent use in patients 13 years or younger. I can find nothing to support this, but did find a half decent study showing some benefit in using it. So what gives? Are we just behind?



When you say the work of breathing wasn't great, do you mean the effort was poor, speaking in one word sentences, lack of chest wall movement?

I spent a portion of my career on a pediatric and neonatal critical care flight program in the D.C. metro area. D.C. has one of the highest childhood asthma rates in the nation, hovering right around 12% or so, and the program that I worked for was pretty aggressive in their asthma managment, based off an Asthma scoring system upon initial assessment. We would give Atrovent x 1 dose, 500mcg like other's have said, without any contraindications for age etc. I am not aware of any information, other then the FDA thing like Remi said, that would prohibit it's usage in the pediatric population, based off my experience.

Couple points with pediatrics and asthma:
-Generally the older kids with asthma are the ones I worry about
-If you're still hearing lung sounds things might not be great, but they can certainly be worse
-Peds with an exacerbation often buy themselves a period of continuous albuterol for an asthma score greater then 5
-Often times in the prehospital world the protocols are pretty tight regarding albuterol dosing in the peds population. A "single" neb would just be 2.5mg, but it's not uncommon to give a "round" or hour long neb of either 7.5mg or 15mg based off weight, coupled with other interventions.
-Peds often respond well to a fluid bolus during an exacerbation, and will often get around 40ml/kg in the ED in an acute asthma flare as a baseline treatment.
-*No insult intended to any of our MD's on the board* Typically most ED docs do a pretty poor job in treating moderate to severe asthma in pediatrics in MOST, not all, community hospitals. I attribute this to a low volume of sick pediatric asthma patient's and a general conservative approach to peds all together in community ED's. 

Intervention wise my treatment plan goes:
-Albuterol/Atrovent x 1 initial 500mcg dose, albuterol being dosed off weight and asthma score
-20ml/kg NS fluid bolus
-Solu-Medrol 2mg/kg max of 125mg
-Re-evaluated need for additional boluses
-Mag Sulfate 75mg/kg up to 2 Grams
-Terbutaline drip 0.1mcg/kg/min
-BiPAP, possible Ketamine dose in the younger kids
-Try and hold intubation unless absolutely needed, and if so generally will end up in the PICU on Isoflurane


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## Bullets (Aug 25, 2015)

Ours is weight based, 25mcg/kg stand alone


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## 18G (Aug 27, 2015)

I have never heard of Atrovent being contraindicated in pediatric patients. In PA, we have it in our protocols as a standing order for asthma. For <14, we give half the adult dose which would be 250mcg. 

A drug doesn't need FDA approval in order for it to be used in a particular patient. We use drugs all the time "off-label". A physician has the right to order and give orders for a drug however he/she sees fit.


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## Chewy20 (Aug 27, 2015)

I can give Atrovent to pts 2 years of age or older at 0.5mg three times. We also go the NS fluid bolus route 20ml/kg as someone stated above. 

Other meds would be:
Solu-medral 2mg/kg max dose 125mg
Epi 0.01mg/kg max dose .3mg
Mag 50mg/kg max dose 2grams


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## Carlos Danger (Aug 27, 2015)

18G said:


> A drug doesn't need FDA approval in order for it to be used in a particular patient. We use drugs all the time "off-label". A physician has the right to order and give orders for a drug however he/she sees fit.



Sure, but there's more to worry about with off-label use, should someone claim they were harmed by the drug.


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## Carlos Danger (Aug 27, 2015)

double post


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## Melbourne MICA (Aug 28, 2015)

250mcg nebulised for all our peds (age<14yrs) with asthma - always has been. i.e. 1/2 the adult dose. Never seen any issues to cause concern when using it.

Melbourne MICA

And on the comment from 18g re his own protocols. <50% of the states in the US have state based protocols employed across the regions in that state or used as a basis for local protocols. What is it when we have power sharing arrangements like county and state governments that they feel they have to do their own thing different from everyone else? You'd have thought in medicine its simply a matter of evidence as to what works best. Not so.


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## Tigger (Aug 29, 2015)

Melbourne MICA said:


> 250mcg nebulised for all our peds (age<14yrs) with asthma - always has been. i.e. 1/2 the adult dose. Never seen any issues to cause concern when using it.
> 
> Melbourne MICA
> 
> And on the comment from 18g re his own protocols. <50% of the states in the US have state based protocols employed across the regions in that state or used as a basis for local protocols. What is it when we have power sharing arrangements like county and state governments that they feel they have to do their own thing different from everyone else? You'd have thought in medicine its simply a matter of evidence as to what works best. Not so.


And it is. But what is necessary for an urban service with short transports and a variety of tertiary care centers may not be the same for a rural service with long transports and no other resources. No sense in including things that are not necessary.


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## Carlos Danger (Aug 29, 2015)

Melbourne MICA said:


> And on the comment from 18g re his own protocols. <50% of the states in the US have state based protocols employed across the regions in that state or used as a basis for local protocols. *What is it when we have power sharing arrangements like county and state governments that they feel they have to do their own thing different from everyone else? You'd have thought in medicine its simply a matter of evidence as to what works best. Not so*.



But very much of medicine _doesn't_ have the advantage of clear evidence as to what the best practice should be. This very topic is a perfect example - I'm not sure atrovent has ever been shown to really improve outcomes in most cases of asthma. At least not that giving it in the field is any better than giving it in the ED. So some medical directors want their crews to use it because they feel it helps, and other docs don't bother putting it in the protocols. The fact that its use in peds is off-label just adds another reason to perhaps leave it out of the protocols, especially if your agency has very short transport times.

Some medical directors like midazolam for seizures; others choose lorazepam. Some prefer ketamine over etomidate. Some want fentanyl given before RSI, others don't. Some want most meds given IM if an IV can't be established, others want an IO placed. No firm body of evidence supporting any of these choices, so the protocols reflect the preferences of the MD's writing them.

These things could all be standardized by a committee in DC writing a set of national ALS protocols, but there'd be individual medical directors all over the country who strongly disagreed with certain parts of the protocols.


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## Melbourne MICA (Aug 30, 2015)

Tigger said:


> And it is. But what is necessary for an urban service with short transports and a variety of tertiary care centers may not be the same for a rural service with long transports and no other resources. No sense in including things that are not necessary.


 


Remi said:


> But very much of medicine _doesn't_ have the advantage of clear evidence as to what the best practice should be. This very topic is a perfect example - I'm not sure atrovent has ever been shown to really improve outcomes in most cases of asthma. At least not that giving it in the field is any better than giving it in the ED. So some medical directors want their crews to use it because they feel it helps, and other docs don't bother putting it in the protocols. The fact that its use in peds is off-label just adds another reason to perhaps leave it out of the protocols, especially if your agency has very short transport times.
> 
> Some medical directors like midazolam for seizures; others choose lorazepam. Some prefer ketamine over etomidate. Some want fentanyl given before RSI, others don't. Some want most meds given IM if an IV can't be established, others want an IO placed. No firm body of evidence supporting any of these choices, so the protocols reflect the preferences of the MD's writing them.
> 
> These things could all be standardized by a committee in DC writing a set of national ALS protocols, but there'd be individual medical directors all over the country who strongly disagreed with certain parts of the protocols.



Agree with all the points except the very reason there are state based guidelines is to overcome the pitfalls of a thousand different protocols depending on what side of the county line you are on. State based guidelines are supposed to (emphasis on _supposed_ to) derive from a consensus judgement of all the stakeholders and utilise an evidence assessment. I'm also channeling my own investigations into the burn first aid situation where there is, basically, no single jurisdiction that does the same thing as another - anywhere in the western world!! And yet a burn is a burn is a burn no matter where you are. Into this mix of local fiefdoms has come the commercial sector out for profit. This has happened with hydrogels. But it doesn't have to be that way. Its just one example but our own organisation brought them in. Then I was asked to do proper research on them exploring the evidence base. The end result is our own CPG's were changed drastically (we dumped them) and even ANZBA changed theirs as well because I presented the findings of my research at a conference - The ANZBA international burns conference in 2011.  (Also partly out of embarrassment because they put out a position statement in 2006 supporting hydrogels) that clearly did not look properly at the evidence). Anyway, enough of my whining.

MM


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## harold1981 (Oct 18, 2015)

In the whole of the Netherlands we use albuterol/atrovent for all pedi patients in case of an astma attack. 
Younger than 4 years: 2,5mg / 0,5mg (standard adult dose)
4 to 18 years: 5mg / 1 mg (which is double the standard dose of an adult patient), this dose may be repeated once should the patient condition not improve.
Solumedrol follows, in a dosis of 25, 50 or 100 mg IV or IM, depending on the age.


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## Aprz (Oct 22, 2015)

I was looking through some notes I saved. Found this and thought of this thread. It's about magnesium vs atrovent in treating asthma.



> This meta-analysis reviewed 40 identified trials, 13 were relevant and eight of these were of high quality. The conclusion of the authors is, “A single dose of an anticholinergic agent is not effective for the treatment of mild and moderate exacerbations and is insufficient for the treatment of severe exacerbations. Adding multiple doses of anticholinergics to beta2 agonists appears safe, improves lung function and would avoid hospital admission in 1 of 12 such treated patients. Although multiple doses should be preferred to single doses of anticholinergics, the available evidence only supports their use in school-aged children with severe asthma exacerbation. There is no conclusive evidence for using multiple doses of anticholinergics in children with mild or moderate exacerbations.”
> http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000060/abstract


https://www.facebook.com/permalink.php?story_fbid=596093183735016&id=287131411297863


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## Doczilla (Nov 12, 2015)

It probably helped because kids are so prone to excess vagal tone; as atrovent only reverses vagally-mediated Bronchospasm.


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