EBQ:Single Dose Dexamethasone in Asthma

Under Review 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.
PubMed Full text PDF

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.

Major Points

• Mean number of days needed for Patient Self Assessment Score to return to baseline (0–0.5) in the Dex and Pred groups were 5.21

versus 5.22 days.

• Pulmonary index scores were similar in both groups at initial presentation, initial ED discharge and at the day 5 follow-up visit.
• At the first visit, mean time to discharge was 3.5 h (±1.93) for Dex and 4.3 h (±3.67) for Pred
• Initial admission rate was 9% (Dex) versus 13.4% (Pred).
• There was no significant difference in the number of salbutamol therapies needed in the ED nor at home after discharge.
• For subjects discharged home, the admission rate after initial discharge was 4.9% (Dex) versus 1.8% (Pred), resulting in overall hospital admission rates of 13.4% (Dex) and 14.9% (Pred)

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 in study received second and third salbutamol 20 minutes apart
  • Decision to give more salbutamol after third dose was up to discretion of attending

Population

Patient Demographics

Dexamethasone vs. Prednisolone Male: 64% vs. 64% Caucasian: 34% vs. 40% Mean age at first diagnosis (months): 26 vs. 28 Mean number of previous hospital admissions: 0.3 vs. 0.4 Mean number of ED visits in last year: 1.6 vs. 1.7 Smokers at home: 16% vs. 15% Pulmonary index score: 1.74 vs. 1.97

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

N=134 eligible subjects consented and enrolled N=110 completed the study, 56 in the Dex group and 54 in the Pred group

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)

Clinical picture	0 points	1 point	2 points	3 points
Wheeze	None	Some	Medium	Severe
Cough	None (0.5 for very occasional cough--<8 coughs in the day, or <2/hr at night)	Occasional	Frequent	Severe
Activity	Normal	Can run only short distances or climb 3 flights of stairs	Can walk not run	Missed school or stayed indoors
Sleep	Normal	Slept well with slight wheeze	Awake 2 to 3 times at night with cough or wheeze	Bad night, awake most of the time

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

Criticisms & Further Discussion

• Primary outcome is clinical scoring system that relies on parental interpretation of patient symptoms
• PEFR is a more valid and reproducible measurement, but was performed in a minority of patients
  • Can only be measured in kids older than 6 years, and in patients who are able to perform the test
• No differentiation made between moderate and severe exacerbations
• Conclusions cannot be extrapolated to patients with severe asthma