EBQ:Single Dose Dexamethasone in Asthma

incomplete Journal Club Article

Altamimi S. et al. "Single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma". Pediatric Emergency Care. 2006. 786-793(22):12.
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Clinical Question

How does a of a single dose of oral dexamethasone compare with 5 days of twice-daily prednisolone in the treatment of mild to moderate asthma exacerbations in children seen in the emergency department?

Conclusion

A single dose of oral dexamethasone (0.6 mg/kg) is no worse than 5 days of twice-daily prednisolone (1 mg/kg per dose) in the management of children with mild to moderate asthma exacerbations.

Study Design

• Prospective, randomized, double-blinded trial conducted at British Columbia Children's Hospital
• All children presenting to the ED with mild to moderate asthma exacerbations were assessed by the emergency attending physician who decided if the child needed treatment with salbutamol
  • Before starting treatment, PIS, vital signs, oxygen saturation, and peak expiratory flow rate (if pt ≥6 years old) were recorded
• Pt reasssesed 20 minutes after first salbutamol, and if further treatment was needed the patient was consented to study
• All patients received second and third salbutamol 20 minutes apart
  • Decision to give more salbutamol after third dose was up to discretion of attending

Population

Inclusion Criteria

• 2-16 years old who presented to the ED with acute mild to moderate asthma exacerbation
  • Mild to moderate asthma exacerbation defined as a Pulmonary Index Score (PIS) of less than 9 or a PEFR ≥ 60% of predicted value by height
• History of at least 1 prior episode of ‘‘asthma-like’’ acute shortness of breath or wheezing that was treated with salbutamol

Exclusion Criteria

• Signs of severe asthma on presentation
  • PEFR < 60%, PIS ≥ 10
• Complete recovery after first salbutamol therapy
• Use of oral steroids in the last 2 weeks
• History of severe asthma exacerbation, including prior intubation or ICU admission for asthma
• Chronic lung disease
• Heart disease
• Neurological disorder
• Psychiatric disease
• History of acute allergic reaction
• Active chickenpox or herpes simplex infections

Interventions

• Patients received single-dose oral dexamethasone (0.6 mg/kg to a maximum of 18 mg) or oral prednisolone (1 mg/kg per dose to a maximum of 30 mg)

twice daily for 5 days

• Pts were contacted by telephone at 48 hrs to assess symptoms and reevaluated in the ED in 5 days

Outcomes

Primary Outcome

• Primary outcome was number of days needed for Patient Self Assessment Score to return to baseline (score of 0-0.5)
  • Mean was 5.21 vs. 5.22 days (Dex vs. Pred)

Secondary Outcomes

• Mean time to discharge: 3.5 hours vs. 4.3 hours
• Initial admission rate: 9% vs. 13.4%
• Re-admission rate after initial discharge: 4.9% vs. 1.8%
• Overall hospital admission rate: 13.4% vs. 14.9%
• No significant difference in the number of salbutamol therapies needed in the ED nor at home after discharge