Medication Summary
Tailor therapy to the underlying disorder whenever possible. Antibiotics are not necessary if the child has asthma and uses oral corticosteroids, frequent inhaled bronchodilators, or high-dose inhaled corticosteroids to address the underlying inflammation and bronchospasm. For more information, see Asthma. The National Asthma Education and Prevention Program (NAEPP) provides detailed information regarding managing children or adults with asthma. For more information see the NAEPP guidelines.[3]
If the child has cystic fibrosis, aggressive antibiotic therapy is indicated in conjunction with chest physical therapy and postural drainage. In children with cystic fibrosis, reducing the load of Pseudomonas species in airways facilitates airway clearance. See Cystic Fibrosis for a more complete discussion on the indications for antibiotics, antibiotics used, and dosing schedule in these patients.
Bronchodilators
Class Summary
These agents decrease muscle tone in the small and large airways in the lungs, thereby increasing ventilation. They are used in children with asthma and are potentially helpful in children with cystic fibrosis.
Albuterol (Ventolin HFA, Proventil HFA, ProAir HFA)
Relaxes bronchial smooth muscle by action on beta2-receptors with little effect on cardiac muscle contractility. First-line bronchodilator that should be used with spacer if using metered dose inhaler.
Systemic corticosteroids
Class Summary
These agents effectively reduce airway inflammation in asthma and cystic fibrosis, which allows easier mobilization of secretions. These also reduce airway reactivity, which might increase propensity to atelectasis.
Prednisone (Deltasone) or prednisolone (Prelone, Orapred)
Corticosteroids that are first-line therapies in the United States.
Both are available in tab and syr; Orapred is available in PO dissolving tab. When choosing syr for children, prednisolone syr is more palatable than prednisone syr.
Inhaled corticosteroids
Class Summary
These agents are safer than systemic corticosteroids for long-term anti-inflammatory effect. Dosing is based on the severity of asthma. Some of the most commonly used inhaled corticosteroids in the United States are listed below.
Fluticasone (Flovent HFA, Flovent Diskus)
Fluticasone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. Available as aerosol, Flovent HFA (44 mcg/actuation, 110 mcg/actuation, or 220 mcg/actuation), also available as Flovent Powder for Inhalation (Diskus) that delivers 50 mcg/actuation, 100 mcg/actuation, or 250 mcg/actuation.
Budesonide inhaled
Budesonide is relatively new to US market but has been extensively used in Europe. It has recently been released in a nebulizer solution approved for use in children as young as 12 mo.
Budesonide decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. Available as Pulmicort Flexhaler, powder for inhalation (90 mcg/actuation and 180 mcg/actuation, each actuation delivers 80 mcg/actuation and 160 mcg respectively) or Pulmicort Respules inhalation susp (0.25 mg/2 mL, 0.5 mg/2 mL, or 1 mg/2 mL). Nebulization has been used in children aged 1-8 y.
Beclomethasone
Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. Available as 40 mcg/actuation or 80 mcg/actuation.
Corticosteroid and bronchodilator combinations
Class Summary
These agents elicit long-acting beta2-adrenergic agonistic and anti-inflammatory effects for persistent asthma.
Fluticasone and salmeterol (Advair HFA, Advair Diskus)
Indicated to treat chronic persistent asthma. Salmeterol component elicits long-acting beta2-adrenergic agonist activity, resulting in bronchiole smooth muscle relaxation. Fluticasone is a corticosteroid that provides anti-inflammatory effects.
Available as powder inhalant containing fluticasone (100 mcg, 250 mcg, or 500 mcg) with salmeterol (50 mcg). HFA preparation in metered dose inhalers has 45, 115 or 230 mcg per puff, each with 21 mcg of salmeterol.
Budesonide/formoterol (Symbicort)
Formoterol relieves bronchospasm by relaxing the smooth muscles of the bronchioles in conditions associated with asthma.
Budesonide is an inhaled corticosteroid that alters level of inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing production of cytokines and other mediators involved in the asthmatic response. Available as MDI in 2 strengths; each actuation delivers formoterol 4.5 mcg with either 80 mcg or 160 mcg.
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