controversies in the ed management of acute asthma fahad al hammad martin v. pusic children’s...

Controversies in the ED Management of Acute Asthma

Fahad al Hammad

Martin V. PusicChildren’s & Women’s Health Centre

Case - Asthma

A 4-year old known asthmatic presents in moderate-severe distress.

Therapy is initiated.

Therapy

• Spacer versus Nebulizer

• Timing of Steroids

• Ipratropium bromide

Therapy

• Spacer versus Nebulizer

• Timing of Steroids

• Ipratropium bromide

Spacers vs. Nebulizers

• July 2001 Cochrane Review

• 16 studies:

686 children and 375 adults

Spacers vs. Nebulizers

• No difference in admission rate• 95% CI ( OR: 0.4 to 2.1 )

• Children’s LOS in the ED shorter• mean diff: -0.62 hours• 95% CI ( -0.84 to -0.40 )

• No difference for LOS in adults

Spacers vs. Nebulizers

Spacers vs. Nebulizers

Key Study:– Chou, Cunningham, Crain

– APAM 1995

Spacers vs. Nebulizers

Chou, Cunningham, Crain– 152 patients > 2 years old

– 3 puffs q20’ w aerochamber

– 0.15mg/kg Ventolin via nebulizer

Spacers vs. Nebulizers

Chou, Cunningham, Crain– Convenience sample

– Unblinded

– Steroids given in ED:– 54% Nebulizer group– 76% in Spacer group

Spacers vs Nebulizers

Time Vomit HR

Spacer 66 9% + 5%

Nebulizer 103 20%+15%

Therapy

• Spacer versus Nebulizer

• Timing of Steroids

• Ipratropium bromide

Steroids

• Cochrane Review: May 2001

• 12 Studies: • 863 Patients• 409 Pediatric

• Main outcome: need for admission

Steroids

Steroids

Number needed to treat with steroids in the first hour to prevent one admission:

Steroids

Number needed to treat with steroids in the first hour to prevent one admission:

6

Steroids

Number needed to treat with steroids in the first hour to prevent one admission:

6

Therapy

• Spacer versus Nebulizer

• Timing of Steroids

• Ipratropium bromide

Ipratropium

• May 2001 Cochrane Review

• 8 studies - considerable heterogeneity

Ipratropium bromide

• Single dose does not work

• Multiple dose decreases admissions• NNT 12 overall 95% CI ( 8, 32 )• NNT 7 severe subgroup 95% CI ( 5,20 )

Ipratropium - Admissions

Qureshi et al.

• Randomized Controlled Trial• 3 doses of IB vs. Placebo• Admission decision at 2-3 hours• Showed marked decrease in

admission rates

Qureshi et al.

Zorc

• Randomized controlled trial

• 3 doses of IB vs. Placebo

• Admission decision at 4 hours• No difference in admission rate

• ED Stay decreased by 23 min.

• Over 4 hours need 1 fewer ventolin

Zorc

Case - Asthma

However, over the next hour he gets worse- sats in low 90’s

- laboured breathing- ICU consulted

Further therapy instituted. Ultimately transferred to the ICU

Therapy

• Magnesium Sulphate

• Theophylline

• IV Salbutamol

Magnesium

• Cochrane Review: May 2001

• 7 trials: 5 adult 2 pediatric

• 665 patients (78 pediatric)

Magnesium

• Outcome -- Admission Rate

• No benefit when all patients treated

• Severe sub-group showed marked significant benefit (90% --> 48% adm)

Magnesium - Admissions

Magnesium

• Dose: 25-100 mg/kg over 20’

• Max: 2 grams

• Obstetrics: 4-5 grams IV load + 10 g IM

Magnesium - Harm?

Magnesium

Key Study: Ciarallo, Sauer, Shannon

• RCT - double-blind• Pediatric ED; Age 6-18 years• PEFR < 60% after 3 albuterol masks• MgSO4: 25mg/kg over 20’ iv

Magnesium

FEV1 FEV1 Adm

50’ 110’

Placebo -1% +5% 16/16

MgSO4 +34% +75% 11/15

Magnesium

Summary

• Spacers -- just as good as Nebulizers

Summary

• Spacers -- just as good as Nebulizers

• Steroids -- good evidence to give in the first hour

Summary

• Spacers -- just as good as Nebulizers

• Steroids -- good evidence to give in the first hour

• Ipratropium -- use multiple doses in mod-severe cases

Summary

• Spacers -- just as good as Nebulizers

• Steroids -- good evidence to give in the first hour

• Ipratropium -- use multiple doses in mod-severe cases

• Magnesium -- use in severe cases

Thank You !!