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Steroids in Pediatric Pulmonary Diseases

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Dr Krishan Chugh, Gurugram    18 January 2018

  1. Prevention of HMD - Antenatal treatment with corticosteroids should be considered for all women at risk for preterm There are 2 major categories of steroids - Systemic and inhaled.
  2. BPD - Early hydrocortisone treatment may be beneficial in a specific population of patients; however, there is insufficient evidence to recommend its use for all infants at risk of BPD. There is insufficient evidence to recommend low-dose dexamethasone. Therapy with high-dose dexamethasone cannot be recommended due to absence of randomized trials. Role of postnasal corticosteroids in chronic lung disease is controversial. Early steroids (<7 days) are not recommended due to poor neurodevelopmental outcome concerns; late steroids (>7 days) should be reserved for infants who cannot be weaned from mechanical ventilation.
  3. ALTB (Croup) - Single dose of long half-life dexamethasone is effective. Nebulized budesonide is effective but more costly.
  4. Stridor: Post-extubation airway obstruction - Based on recent adult studies, it can be concluded that IV corticosteroids are effective in the prevention of post-extubation laryngeal edema (PLE)/stridor if started 4-48 hours before extubation.
  5. Stridor: Foreign body - Corticosteroids are not indicated before removal. After removal, a corticosteroid may be administered if significant swelling is observed in the airway or if granulation tissue is present.
  6. Bronchiolitis - AAP 2014 guidelines conclude that clinicians should not administer systemic corticosteroids to infants with a diagnosis of bronchiolitis in any setting.
  7. Bronchiectasis - Current BTS guidelines found no evidence for or against the use of oral steroids. A wider group of patients with obvious asthma (which may coexist with bronchiectasis) will primarily be managed with inhaled corticosteroids. A small percentage with difficult asthma may require a maintenance dose of oral steroids.
  8. Cystic fibrosis - For CF without asthma and allergic bronchopulmonary aspergillosis (ABPA), the CF Foundation recommends against chronic use of systemic corticosteroids to reduce exacerbations or improve lung function or quality-of-life.
  9. PCP - Adjunctive corticosteroids for moderate-to-severe PCP are advocated based on the following criteria: PaO2 <70 mmHg at room air, or alveolar-arterial O2 gradient ≥35 mmHg.
  10. TB - Steroids are indicated in tubercular meningitis, tubercular pericardial effusion, PTB with respiratory distress, PTB with airway obstruction by hilar lymph nodes, severe military TB.
  11. ABPA - Systemic steroids are effective first-line treatment for ABPA in both asthma and CF.
  12. ARDS - Corticosteroids cannot be recommended as routine therapy in PARDS at this time.
  13. Hydrocarbon pneumonitis - Use of steroids to treat chemical pneumonitis is still controversial.
  14. Lipoid pneumonia - Steroids have been used for decades but there is limited data to support this practice.
  15. chILD - The decision about whether or not to initiate a trial of immunosuppressive therapy must be made on a case-by-case basis.
  16. Pulmonary sarcoidosis - Steroids should be reserved to symptomatic patients (dyspnea, cough, chest pain/severe impairment of PFT).
  17. Under 5 wheeze - Wheezing episodes in young children should be treated initially with inhaled short-acting b2 agonists, regardless of whether the diagnosis of asthma has been made.

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