McMASTER NICU INHALED STEROIDS FOR EVOLVING BPD (GA < 29 WEEKS)

Transcription

1 McMASTER NICU INHALED STEROIDS FOR EVOLVING BPD (GA < 29 WEEKS) Developed by: Amit Mukerji, Samira Samiee-Zafarghandy, Jennifer Twiss, Ereny Bassilious, Elizabeth Vo, Shari Gray, Salhab el Helou on behalf of McMaster NICU BPD Review Group Indications: Endotracheal ventilation on DOL 5 (for primary parenchymal pulmonary pathology) Non-invasive respiratory support (NRS) with FiO 2 > on DOL 5 Medication/dose/delivery: Inhaled budesonide 500 ug Q12H (1000 ug per day) Delivered via Aerogen nebulizer: o For intubated patients o For patients on NRS Duration: Until FiO 2 < 0.25 on NRS with MAP < 8 cmh 2O If no response (FiO 2 or respiratory support settings) in 1 week, consider stopping Stop if started on systemic steroids, then resume if criteria under Indications still present at end of systemic steroid course Monitoring/Safety: Glucose (for first 72 hours only), BP q-shift while on inhaled steroids Routine monitoring of growth parameters Prophylactic oral Nystatin while on inhaled steroids No need for baseline cortisol levels o If 2 weeks of treatment duration (including systemic steroids), taper over 2 weeks, as follows 250 ug Q12H x 7 days; 250 ug Q24H x 7 days

2 Indications Endotracheal ventilation on DOL 5 (for primary parenchymal pulmonary pathology) Non-invasive respiratory support (NRS) w/ Fi0 2 > YES Start Budesonide Dose Inhaled Budesonide 500 ug Q12H (1000 ug per day) Response within a week? (FiO 2 or respiratory support settings) Delivered via Aerogen Nebulizer For intubated patients and patients on NRS NO YES Consider Stopping Continue until: Fi0 2 < 0.25 on NRS with MAP < 8 cmh 20 If 2 weeks duration, taper over 2 weeks as follows: 250 ug Q12H x 7 days 250 ug Q24H x 7 days Safety Monitoring Glucose (1 st 72 hrs only), and BP Q-shift Routine growth monitoring Prophylactic oral Nystatin No need for baseline cortisol levels

3 Risk of Adrenal suppression: No routine checks for cortisol levels at any time If inhaled steroids duration 2 weeks, and until 8 weeks following cessation of inhaled steroids, patient is assumed to have secondary adrenal insufficiency. o Please note that adrenal insufficiency may ensue with a shorter duration of steroid therapy and therefore a high index of suspicion for adrenal insufficiency is recommended for any patient on steroids who has a clinical deterioration and need for stress dosing in those patients (discretion of medical team). Stress dosing with hydrocortisone for patients assumed/confirmed to have secondary adrenal insufficiency: For sedation for a significant procedure or diagnostic imaging o Hydrocortisone (IV): 40mg/m2BSA x 1 dose, no further doses needed if clinically stable For minor/minimally invasive surgery (including Avastin eye injections for ROP) o Hydrocortisone (IV): 40mg/m2 x1 dose, followed 6 hours later by 10mg/m2 BSA po/ng/iv q6h x24 hours then reassess [no need to wean] If significant inter-current illness during at risk period (defined as need for initiation of inotropes/pressors), OR for major/prolonged surgery o Hydrocortisone (IV): 100 mg/m2bsa x 1 dose, then 6 hours later 25 mg/m2bsa po/ng/iv Q6 x 24 hours then re-assess [no need to wean] Assessment for recovery of adrenal function At 8 weeks post-cessation of inhaled steroids or prior to discharge home**, whichever is sooner, confirm normal HPA axis function by first: o Random cortisol if >270mmol/L can assume adrenal sufficiency and no need for ACTH stimulation test o If Random cortisol 270mmol/L, perform ACTH stim test as follows: ACTH stim test (1 mcg Cosyntropyn with cortisol levels drawn at baseline, and 20, 30, 60 minutes after cosyntropyn administration) may be performed at level 2 nursery. A cortisol level of >500 indicates adrenal sufficiency. Cortisol <500 patient is adrenally insufficient and continues to require stress dosing. Consult pediatric endocrinology or if patient is in community hospital physician to call endocrinologist on call to arrange a referral. ** If destination Level 2 hospital is unable to perform ACTH stim test, then perform it at McMaster prior to transfer.

4 8 weeks following cessation of inhaled Budesonide (or prior to discharge, if sooner) Random cortisol ACTH Stim test No further testing required ACTH Stim test 1 mcg Cosyntropyn w/ cortisol levels drawn at baseline, and 20, 30, 60 minutes after cosyntropyn administration 500* 500 No further testing required Consult Pediatric Endocrinology * On any one of 20, 30, 60 min samples Patient should be assumed to have adrenal insufficiency (until further assessment by Peds Endo)

5 References 1. Bassler D et al. Inhaled Drugs and Systemic Corticosteroids for Bronchopulmonary dysplasia. Pediatr Clin N Am 2017 (64): Bassler D et al. Early Inhaled Budesonide for the Prevention of Bronchopulmonary Dysplasia. N Engl J Med 2015 (373): Bassler D et al. Long-Term Effects of Inhaled Budesonide for Bronchopulmonary Dysplasia. N Engl J Med 2018 (378): Shah V et al. Early administration of inhaled corticosteroids for preventing chronic lung disease in very low birth weight preterm neonates (Review). Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD Shinwell ES et al. Inhaled Corticosteroids for Bronchopulmonary Dysplasia: A Meta-analysis. Pediatrics 2016 (138):e Cole CH et al. Early inhaled glucocorticoid therapy to prevent Bronchopulmonary dysplasia. N Engl J Med 1999 (340): Nakamura T et al. Early inhaled steroid use in extremely low birthweight infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2016(101):F552 F556