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Safety and efficacy of theophylline in children with asthma
Abstracts
need for determination of electrolyte, calcium, and magnesium levels should be based on physical examination findings.
? ?SAFETY AND EFFICACY OF THEOPHYLLINE IN CHILDREN WITH ASTHMA. Hendeles L, Weinberger M, Szefler S, Ellis E. J Pediatr. 1992;120:177-83. This article was written in response to the growing concern over the potentially adverse effects of theophylline in children. Theophylline-induced seizures with subsequent encephalopathy as well as possible learning and behavior disorders are addressed. The benefits of theophylline in severe asthma as a maintenance drug often outweigh the risks. There were two reported cases of encephalopathy due to severe seizures; however, the parents failed to recognize repeated vomiting as a sign of toxicity. Further, the FDA released a review concluding that there is insufficient data to prove any learning or behavioral problems to be due to theophylline. Parents should be educated to recognize the signs of theophylline toxicity as well as conditions or drugs that can change the existing serum theophylline level. This article has a detailed chart on dosing, as well as an algorithm for slow clinical titration of theophylline based on the serum concentration. The recommended guidelines to ensure the safe use of theophylline include: Always guide final dosage by serum theophylline concentrations. ?? Theophylline should be withheld for persistent headache, nervousness, tachycardia, nausea, or vomiting. ?? Reduce dosage by half for fever sustained more than 24 hours. ?? Reduce dosage by one-third if the patient begins erythromycin or ciprofloxacin, and by half for cimetidine, troleandomycin, or oral contraceptives. ?? Reduce dosage by half if carbamazepine or phenytoin is discontinued. ?? Provide adequate instruction so that everyone understands the benefits and risks of theophylline. [Susan Taylor, MD] Editor’s Comment: With encouraging data regarding the long-term use of inhaled corticosteroids, the risk/benefit ratio of chronic theophylline therapy needs to be reexamined.
653 awake tracheal intubation over the study period. Between 1980 and 1987 the charts of all patients with cervical spine injuries (with or without spinal cord injury) were reviewed. Patients were excluded if they were intubated under general anesthesia (mainly at the referring hospital), received a surgical airway, had a cervical spine injury of indeterminate age, or had severe head injury precluding the adequate assessment of spinal function. Eighty patients were excluded. Of the remaining 454 patients, 289 controls did not require tracheal intubation, and 165 cases required tracheal intubation. Intubations were performed without the aid of general anesthesia or muscle relaxants. The comparison of neurological status between admission and discharge revealed no statistically significant difference in neurological deterioration between the controls (2.4%) and the cases (2.4%). There was no ‘documented evidence of aspiration in the case group. These results occurred despite the case group having a higher injury severity score. The authors note that 42 patients (25%) were intubated before any form of rigid immobilization was applied, and that 64 patients (39%) were intubated. under emergent conditions. They conclude that awake tracheal intubation is a safe method of airway management in patients with cervical spine injuries. [Steven A. Kohler, MD] Editor’s Comment: Endotracheal intubation was achieved with fiberoptic guidance in almost half of these patients and may be the method of choice in cases of cervical spine injury when time allows.
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0 THE SAFETY OF AWAKE TRACHEAL INTUBATION IN CERVICAL SPINE INJURY. Meschino A, Hugh Devitt J, Koch J-P, Szalai JP, Schwartz ML. Can J Anaesth. 1992;39:2. This retrospective, case control study reviewed the frequency of neurological deterioration and aspiration associated with awake tracheal intubation of cervical spine injured patients. It was undertaken at a referral center for cervical spine injuries. This institution routinely performed
0 MANAGEMENT OF THE DIFFICULT ADULT AIRWAY WITH SPECIAL EMPHASIS ON AWAKE TRACHEAL INTUBATION. Bleubuyck JF. Anesthesiology. 1991;75: 1087-l 10. Management of the difficult airway is an area of critical concern to the fields of emergency medicine and anesthesiology. In this article, the author provides an extensive review of methods of recognizing and securing the difficult airway with particular attention to techniques of awake intubation, the method of choice when difficulty in securing an airway is expected. Methods of upper airway anesthesia include topical anesthesia, lingual block, and superior laryngeal nerve block, with an emphasis on safety. Various methods of tracheal intubation are described and contrasted, including direct laryngoscopy, blind nasal intubation, retrograde intubation, and flexible fiberoptic bronchoscopy. Special situations such as the patient with a full stomach and the patient who is obtunded are discussed. Finally, methods of securing an airway when a patient cannot be ventilated by bag-valve-mask are discussed, such as the combitube, laryngeal mask airway, and transtracheal [Michael D. Witting, MD] jet ventilation.
0 PREDICTING CM. Anaesthesia.
DIFFICULT INTUBATION. 1991;46:1005-8.
Frerk
need for determination of electrolyte, calcium, and magnesium levels should be based on physical examination findings.
? ?SAFETY AND EFFICACY OF THEOPHYLLINE IN CHILDREN WITH ASTHMA. Hendeles L, Weinberger M, Szefler S, Ellis E. J Pediatr. 1992;120:177-83. This article was written in response to the growing concern over the potentially adverse effects of theophylline in children. Theophylline-induced seizures with subsequent encephalopathy as well as possible learning and behavior disorders are addressed. The benefits of theophylline in severe asthma as a maintenance drug often outweigh the risks. There were two reported cases of encephalopathy due to severe seizures; however, the parents failed to recognize repeated vomiting as a sign of toxicity. Further, the FDA released a review concluding that there is insufficient data to prove any learning or behavioral problems to be due to theophylline. Parents should be educated to recognize the signs of theophylline toxicity as well as conditions or drugs that can change the existing serum theophylline level. This article has a detailed chart on dosing, as well as an algorithm for slow clinical titration of theophylline based on the serum concentration. The recommended guidelines to ensure the safe use of theophylline include: Always guide final dosage by serum theophylline concentrations. ?? Theophylline should be withheld for persistent headache, nervousness, tachycardia, nausea, or vomiting. ?? Reduce dosage by half for fever sustained more than 24 hours. ?? Reduce dosage by one-third if the patient begins erythromycin or ciprofloxacin, and by half for cimetidine, troleandomycin, or oral contraceptives. ?? Reduce dosage by half if carbamazepine or phenytoin is discontinued. ?? Provide adequate instruction so that everyone understands the benefits and risks of theophylline. [Susan Taylor, MD] Editor’s Comment: With encouraging data regarding the long-term use of inhaled corticosteroids, the risk/benefit ratio of chronic theophylline therapy needs to be reexamined.
653 awake tracheal intubation over the study period. Between 1980 and 1987 the charts of all patients with cervical spine injuries (with or without spinal cord injury) were reviewed. Patients were excluded if they were intubated under general anesthesia (mainly at the referring hospital), received a surgical airway, had a cervical spine injury of indeterminate age, or had severe head injury precluding the adequate assessment of spinal function. Eighty patients were excluded. Of the remaining 454 patients, 289 controls did not require tracheal intubation, and 165 cases required tracheal intubation. Intubations were performed without the aid of general anesthesia or muscle relaxants. The comparison of neurological status between admission and discharge revealed no statistically significant difference in neurological deterioration between the controls (2.4%) and the cases (2.4%). There was no ‘documented evidence of aspiration in the case group. These results occurred despite the case group having a higher injury severity score. The authors note that 42 patients (25%) were intubated before any form of rigid immobilization was applied, and that 64 patients (39%) were intubated. under emergent conditions. They conclude that awake tracheal intubation is a safe method of airway management in patients with cervical spine injuries. [Steven A. Kohler, MD] Editor’s Comment: Endotracheal intubation was achieved with fiberoptic guidance in almost half of these patients and may be the method of choice in cases of cervical spine injury when time allows.
??
0 THE SAFETY OF AWAKE TRACHEAL INTUBATION IN CERVICAL SPINE INJURY. Meschino A, Hugh Devitt J, Koch J-P, Szalai JP, Schwartz ML. Can J Anaesth. 1992;39:2. This retrospective, case control study reviewed the frequency of neurological deterioration and aspiration associated with awake tracheal intubation of cervical spine injured patients. It was undertaken at a referral center for cervical spine injuries. This institution routinely performed
0 MANAGEMENT OF THE DIFFICULT ADULT AIRWAY WITH SPECIAL EMPHASIS ON AWAKE TRACHEAL INTUBATION. Bleubuyck JF. Anesthesiology. 1991;75: 1087-l 10. Management of the difficult airway is an area of critical concern to the fields of emergency medicine and anesthesiology. In this article, the author provides an extensive review of methods of recognizing and securing the difficult airway with particular attention to techniques of awake intubation, the method of choice when difficulty in securing an airway is expected. Methods of upper airway anesthesia include topical anesthesia, lingual block, and superior laryngeal nerve block, with an emphasis on safety. Various methods of tracheal intubation are described and contrasted, including direct laryngoscopy, blind nasal intubation, retrograde intubation, and flexible fiberoptic bronchoscopy. Special situations such as the patient with a full stomach and the patient who is obtunded are discussed. Finally, methods of securing an airway when a patient cannot be ventilated by bag-valve-mask are discussed, such as the combitube, laryngeal mask airway, and transtracheal [Michael D. Witting, MD] jet ventilation.
0 PREDICTING CM. Anaesthesia.
DIFFICULT INTUBATION. 1991;46:1005-8.
Frerk