Non-evidence-based thread!:

There was more discussion on Twitter about weaning #salbutamol in children after an acute #asthma attack in hospital - In my humble opinion we should just stop salbutamol instead of the random weaning process, and here's my meandering rationale

Here's what's happening in acute asthma - in this lung model made by @kchickman's daughter the problem would be largely in the bronchioles... inflammation, bronchoconstriction, and mucus. The primary problem being a cheeky bit of profound self-perpetuating inflammation (note IL6)

So why 'wean' anything? Basically to stop some sort of rebound phenomenon. By weaning, we saturate salbutamol receptors and (if anything) increase the risk of rebound when we think the child is better! Also the risk of tachyphylaxis: the more you give the less effective it is

There is no pharmacological rationale to weaning. Halflife of salbutamol is 4 hours and they will have had LOADS before coming in and after they arrive in hospital. There is some (weak) evidence for high dose of IV salbutamol, but nothing that 'keeping them topped up' is useful

So if anything we only add to the risk of side effects - hypokalaemia, tachycardia, tremor, nausea and importantly INFLAMMATION... yes, that's right - in some patients salbutamol can be pro-inflammatory esp IL6 and eosinophils (as shown earlier, these are naughty in asthma!)

Even if we did want to wean, there is no structured, evidence-based way of doing this. We are just making it up on the basis of signs that don't correlate with asthma severity (how loud is the wheeze etc). Its all wooly and meaningless, and confusing for the family

Patient perception of worsening is important in determining whether someone is getting worse - by just dosing them up with salbutamol we might mask what's going on - and we disempower the child from understanding in a controlled situation what to do if their asthma gets worse

While children are in hospital we wake them up at random times to give salbutamol that they dont need... and sleep is an important part of recovering from an asthma attack. Imagine how you feel when air hostesses wake you up at peanut time - then imagine you're acutely unwell!

We are really really bad at doing inhaler technique and action plan before discharge - and I think once children are well they (and us) are keen for discharge. Time spent weaning would be better spent educating and empowering self-management. We can observe for deterioration ..

... and if they're ok, they're ok! They can go home ONCE WE'VE DONE INHALER TECHNIQUE AND WRITTEN ACTION PLAN! And we will have observed on the dose they will use at home rather than making them wean after discharge (again, disempowering)

Nurses have a crucial role in advocating what's best for the child. We dont love you because you follow random protocols - we love you because you so often know what's best for kids!

And so the point is this - if the child needs salbutamol at 5 minutes or 1 hour or 2 hours or 4 hours, enable them to tell you that...in a controlled situation we can help them learn what to do during asthma attacks. Thats way more empowering than random fixed weaning protocols

Empower children and empower nurses x

@Tomcromarty @Damian_Roland @drtimmason @DFTBubbles @PERUKItweep @Pharmaforkids @heretolearnkids @bigcatdoc @PrasadNagakumar @Lungclinic @LouiseTurnbul17 @NACAPaudit

Tom started the discussion, here's my thoughts, feel free to rip apart!

And of course, as highlighted by @Logical1966 , empower parents as well as kids... parents have such an important role in managing their child’s asthma and we should build our services to make sure they feel in control