EBQ:Single Dose Dexamethasone in Asthma: Difference between revisions
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{{JC info | |||
| title= Single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma | |||
| abbreviation= Dex in Peds Asthma | |||
| expansion=Single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma | |||
| published= 2006 | |||
| author= Altamimi S. et al | |||
| journal= Pediatric Emergency Care | |||
| year= 2006 | |||
| volume= 786-793 | |||
| issue= 22 | |||
| pages= 12 | |||
| pmid= 17198210 | |||
| fulltexturl= http://journals.lww.com/pec-online/Abstract/2006/12000/Single_Dose_Oral_Dexamethasone_in_the_Emergency.3.aspx | |||
| pdfurl= http://www.infomine.com/publications/docs/asthmapaper.pdf | |||
| status=Complete | |||
}} | |||
==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 vs. 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. | |||
*Overall hospital admission rates were 13.4% (Dex) vs. 14.9% (Pred) | |||
*There was no significant difference in the number of salbutamol therapies needed in the ED nor at home after discharge. | |||
==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''' <br/> | |||
Male: 64% vs. 64% <br/> | |||
Caucasian: 34% vs. 40% <br/> | |||
Mean age at first diagnosis (months): 26 vs. 28 <br/> | |||
Mean number of previous hospital admissions: 0.3 vs. 0.4 <br/> | |||
Mean number of ED visits in last year: 1.6 vs. 1.7 <br/> | |||
Smokers at home: 16% vs. 15% <br/> | |||
Pulmonary index score: 1.74 vs. 1.97 <br/> | |||
===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 (seen in table below) to return to baseline (score of 0-0.5) | |||
**Mean was 5.21 vs. 5.22 days (Dex vs. Pred) | |||
{| class="wikitable" | |||
|- | |||
! 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 | |||
===Subgroup analysis=== | |||
==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, so fine treatment differences cannot be determined | |||
*Only patients with mild and moderate asthma exacerbations were included in the study, so conclusions cannot be extrapolated to patients with severe asthma | |||
*In another study ED based study, a 2 day dosing of dexamethasone in adults (18-45 yo) was found to be at least effective as 5 days of oral prednisone in preventing relapse and resolving the exacerbation. | |||
*A meta-analysis in 2014 found no difference in relative risk of relapse between children (≤18) treated with dexamethasone (1 or 2 dose regimens) compared to 5 day oral prednisone<ref>Keeney GE et al. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014 Mar;133(3):493-9.</ref> | |||
==Funding== | |||
*Peak flow meters provided by Trudell Medical | |||
==Sources== | |||
<references/> | |||
[[Category:EBQ]] | |||
[[Category:Pediatrics]] |
Latest revision as of 15:59, 22 March 2016
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 vs. 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.
- Overall hospital admission rates were 13.4% (Dex) vs. 14.9% (Pred)
- There was no significant difference in the number of salbutamol therapies needed in the ED nor at home after discharge.
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 (seen in table below) 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
Subgroup analysis
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, so fine treatment differences cannot be determined
- Only patients with mild and moderate asthma exacerbations were included in the study, so conclusions cannot be extrapolated to patients with severe asthma
- In another study ED based study, a 2 day dosing of dexamethasone in adults (18-45 yo) was found to be at least effective as 5 days of oral prednisone in preventing relapse and resolving the exacerbation.
- A meta-analysis in 2014 found no difference in relative risk of relapse between children (≤18) treated with dexamethasone (1 or 2 dose regimens) compared to 5 day oral prednisone[1]
Funding
- Peak flow meters provided by Trudell Medical
Sources
- ↑ Keeney GE et al. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014 Mar;133(3):493-9.