EBQ:Single Dose Dexamethasone in Asthma

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Complete 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 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

  1. Keeney GE et al. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014 Mar;133(3):493-9.