PEM journal club: Asthma protocol

Hey everyone,
This year the PEM fellows have decided to do PEM Journal club a little differently from last year. Periodically we will critically appraise the evidence behind the clinical protocols that we currently use in our Pediatric ED to better understand why we do what we do. 

For our first protocol, we reviewed the new Peds ED Asthma Pathway. Below are the take home points for the main topics that we discussed.

Enjoy!
- Kat Bryant

​Dexamethasone vs Prednisolone:

• ​PEM Consensus:
  • Dexamethasone was shown to be better tolerated, cheaper, has better patient/parent satisfaction with less concern for compliance issues
  • No difference was found in relapse rate or incidence of vomiting with 1-2 doses of Dexamethasone compared to 3-day course of Prednisolone
  • Dexamethasone is likely non-inferior to Prednisolone for the treatment of acute asthma exacerbations
• Articles:
  • Altamimi, S., et al., Single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma. Pediatr Emerg Care, 2006. 22(12): p. 786-93.
  • ​Cronin, J.J., et al., A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Ann Emerg Med, 2016. 67(5): p. 593-601 e3.
  • Greenberg, R.A., G. Kerby, and G.E. Roosevelt, A comparison of oral dexamethasone with oral prednisone in pediatric asthma exacerbations treated in the emergency department. Clin Pediatr (Phila), 2008. 47(8): p. 817-23.
  • Qureshi, F., A. Zaritsky, and M.P. Poirier, Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma. J Pediatr, 2001. 139(1): p. 20-6.

​When to add anticholinergics to short acting beta agonists:

• PEM Consensus
  • Children with moderate to severe asthma exacerbations benefited from receiving anticholinergics with decreased stay duration and decreased number of subsequent interventions
  • Anticholinergics haven’t been shown to be beneficial in mild exacerbations
  • Data suggests, but has not proven, that multiple doses of anticholinergics are more beneficial
• Articles:
  • Griffiths, B. and F.M. Ducharme, Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. Paediatr Respir Rev, 2013. 14(4): p. 234-5.
  • Rodrigo, G.J. and J.A. Castro-Rodriguez, Anticholinergics in the treatment of children and adults with acute asthma: a systematic review with meta-analysis. Thorax, 2005. 60(9): p. 740-6.
  • Zorc, J.J., et al., Ipratropium bromide added to asthma treatment in the pediatric emergency department. Pediatrics, 1999. 103(4 Pt 1): p. 748-52.

Why use Magnesium:

• PEM Consensus:
  • Magnesium’s exact mechanism of action for bronchodilation unclear
  • Magnesium may be beneficial for decreased severity of exacerbation, may prevent hospital admission/ICU admission
  • Magnesium requires monitoring for hypotension, but has not been shown to cause significant harm
• Articles:
  • Alansari, K., et al., Nebulized magnesium for moderate and severe pediatric asthma: A randomized trial. Pediatr Pulmonol, 2015. 50(12): p. 1191-9.
  • Colleti, J., Jr. and W.B. de Carvalho, Magnesium Sulfate for Acute Asthma in Children: A Good Option, but How to Use It? Pediatr Crit Care Med, 2016. 17(5): p. 477-8.
  • Kokotajlo, S., et al., Use of intravenous magnesium sulfate for the treatment of an acute asthma exacerbation in pediatric patients. J Pediatr Pharmacol Ther, 2014. 19(2): p. 91-7