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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 !!
