How Emergency Medicine Physicians Treat Pediatric Acute Severe Asthma

The National Heart, Blood, and Lung Institute Asthma Guidelines were created by an expert panel on essential components of asthma care. They were originally released in 1991 and have since been updated in 1997 and 2007. Roua Azmeh, MD, of Saint Louis University School of Medicine in Missouri, and colleagues set out to uncover how particular asthma cases were actually handled in the emergency department setting.

Presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology (AAAAI 2017) in Atlanta, the aim of the study was to understand how residency program directors (PDs) in pediatric critical care (PDs-PCC) and pediatric emergency medicine (PDs-PEM) in the United States treated pediatric acute severe asthma.

Surveys were administered to PDs-PCC and PDs-PEM in both 1995 and 2016. Of the 144 PDs emailed the most recent survey, 62 (43%) completed it.

All of the participants reported using B2-agonists and corticosteroids for initial management (IT). More PDs-PCC used parenteral corticosteroids than PDs-PEM (85% vs. 32%, P < 0.0001). In addition, more of them used B2-agonists (73% vs. 56%, P < 0.05), Azmeh explained.

Although 98.4% of participants said that they did not use theophylline for IT, they did more so for treatment failure (TF). However, that statistic was again higher in the PDs-PCC than the PDs-PEM (56.3% vs. 20%, P < 0.0071). The current guidelines say that sustained-release theophylline can be an alternative for mild persistent asthma, but isn’t preferred. It can also be used as an alternative addition to ICS, however, that is not preferred either.

Looking at both groups of PDs, heliox was used more in TF cases than IT (13% vs. 1.6%). The guidelines advise that for severe exacerbations in the emergency department, physicians should reduce dose and frequency of administration of oral corticosteroids. They can also consider adding magnesium sulfate or heliox in these situations. These severe exacerbation cases might also call for initiating an inhaled corticosteroid (ICS) upon hospital discharge.

“Comparing the 2016 and 1995 surveys, both the PDs-PCC and PDs-PEM are now more likely to use a combination of oral and parenteral corticosteroids (rather than only parenteral) in both IM and TF, are more likely to use ipratropium bromide and less likely to use theophylline in IM,” the researchers explained.

The guidelines indicate that these emergency department visits for acute severe asthma present another opportunity for clinicians to educate patients, as well as parents, on better asthma self-management.

“Overall, these components have stood the test of time, and many of the earlier recommendations have been solidly confirmed by additional research throughout the years,” William W. Busse, MD, chairman of the Expert Panel, said about the guidelines.

The latest version of The National Heart, Blood, and Lung Institute Asthma Guidelines can be found here.

The study, “Twenty-one Year Trends in the Treatment of Pediatric Acute Severe Asthma by Pediatric Emergency Medicine and Critical Care Program Directors,” was published in The Journal of Allergy and Clinical Immunology.

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