Practice Based Learning: In which asthmatic children should we start PEP on admission, and in which children do we not need to start PEP?

Lauren Levy, MD

Presented by Lauren Levy, MD
Resident, Department of Pediatrics
Emory University

Key Points:

  • Use of PEP in combination with nebulized bronchodilators is useful in increasing delivery and distribution (as evidenced by a study utilized scintigraphy) of the drug in an outpatient setting, and may be extrapolated to have benefits in the acute care setting as well.
  • Other types of NiPPV (such as BIPAP) have been shown to improve outcomes in acute presentations in asthmatics, likely by stenting airways and improving drug delivery, along with decreasing atelectasis and air trapping. This has been shown to decrease length of ICU stays as well as to lower the mean dose of the bronchodilator needed.
  • More studies need to be conducted to look at the use of PEP with bronchodilators specifically in the ED and inpatient setting to evaluate its potential benefits.

References:

Alcoforado L, Brandão S, Rattes C, Brandão D, Lima V, Ferreira Lima G, Fink JB, Dornelas de Andrade A. Evaluation of lung function and deposition of aerosolized bronchodilators carried by heliox associated with positive expiratory pressure in stable asthmatics: A randomized clinical trial. Respir Med. 2013 May 8. PMID: 23664767.

Brandao DC, Lima VM, Filho VG, Silva TS, Campos TF, Dean E, de Andrade AD. Reversal of bronchial obstruction with bi-level positive airway pressure and nebulization in patients with acute asthma. J Asthma. 2009 May;46(4):356-61. PMID: 19484669.

Gupta D, Nath A, Agarwal R, Behera D. A prospective randomized controlled trial on the efficacy of noninvasive ventilation in severe acute asthma. Respir Care. 2010 May;55(5):536-43. PMID: 20420722.

Schramm CM, Carroll CL. Advances in treating acute asthma exacerbations in children. Curr Opin Pediatr. 2009 Jun;21(3):326-32. PMID: 19387346.

Slats AM, Janssen K, de Jeu RC, van der Plas DT, Schot R, van den Aardweg JG, Sterk PJ. Enhanced airway dilation by positive-pressure inflation of the lungs compared with active deep inspiration in patients with asthma. J Appl Physiol. 2008 Dec;105(6):1725-32. PMID: 18801966.

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