Inhaled short-acting bronchodilators for managing emergency childhood asthma: an overview of reviews

Abstract

International guidelines provide conflicting recommendations on how to use bronchodilators to manage childhood acute wheezing conditions in the emergency department (ED), and there is variation within and among countries in how these conditions are managed. This may be reflective of uncertainty about the evidence. This overview of systematic reviews (SRs) aimed to synthesize, appraise, and present all SR evidence on the efficacy and safety of inhaled short-acting bronchodilators to treat asthma and wheeze exacerbations in children 0-18 years presenting to the ED. Searching, review selection, data extraction and analysis, and quality assessments were conducted using methods recommended by The Cochrane Collaboration. Thirteen SRs containing 56 relevant trials and 5526 patients were included. Results demonstrate the efficacy of short-acting beta-agonist (SABA) delivered by metered-dose inhaler as first-line therapy for younger and older children (hospital admission decreased by 44% in younger children, and ED length of stay decreased by 33 min in older children). Short-acting anticholinergic (SAAC) should be added to SABA for older children in severe cases (hospital admission decreased by 27% and 74% when compared to SABA and SAAC alone, respectively). Continuous nebulization, addition of magnesium sulfate to SABA, and levosalbutamol compared to salbutamol cannot be recommended in routine practice.Acute wheeze in children is one of the most common reasons for presentation to the emergency departments (ED) (1). In school-aged children, acute wheeze usually signifies underlying asthma, while in preschool children this sign may be the result of either asthma or viral-induced wheeze with distinct phenotypes and underlying mechanisms. In these age groups, regardless of the underlying pathology, exacerbations of recurrent wheeze and dyspnoea are largely caused by bronchoconstriction of the small airways. Although most children improve with bronchodilator therapy, many require hospital admission, and others may even require admission to critical or intensive care units. It is important, therefore, that children with wheeze and dyspnoea are treated promptly and appropriately in the ED to reduce symptoms and respiratory distress, mitigate hospital admission, and prevent respiratory failure. Across the UK and many other countries, there is a 10-fold difference in rates of hospital admission for acute asthma in children (2).Although the reasons for this are complex, one factor may be variations among EDs in the management of pediatric asthma, which have recently been described for key interventions such as inhaled bronchodilators (3).The three most common groups of inhaled bronchodilators used to treat acute asthma and wheeze in EDs are short-acting beta-agonists (SABA) such as salbutamol (albuterol), levosalbutamol (levalbuterol), and adrenaline (epinephrine); short-acting anticholinergics (SAACs) such as ipratropium bromide; and, more recently, a third category of muscle relaxants comprising magnesium sulfate (MgSO ...

In vitro comparison of unit dose vs infusion pump administration of albuterol via high‐flow nasal cannula in toddlers

“…Asthma impacts more than 6 million American children, with asthma exacerbation a leading cause for pediatric hospitalization . Short‐acting β‐agonist bronchodilator is recommended as first‐line therapy for emergency childhood asthma . During exacerbations of severe asthma, high doses such as 2.5 mg every 20 minutes is recommended by the National Asthma Education and Prevention Program; however, the frequently repeated doses delivered by small volume nebulizer (SVN) is time‐consuming for clinicians .…”

“…3 During exacerbations of severe asthma, high doses such as 2.5 mg every 20 minutes is recommended by the National Asthma Education and Prevention Program 4 ; however, the frequently repeated doses delivered by small volume nebulizer (SVN) is time-consuming for clinicians. 5 As a result, for more than 20 years continuous nebulization with higher doses such as 10 to 20 mg/hr delivered by a large volume jet nebulizer or SVN with continuous feed from an infusion pump has been utilized as an alternative to repeated intermittent unit doses, with greater benefit reported in improving clinical severity score, 3 as well as improvement in ventilation and avoidance of intubation. [6][7][8][9] Intolerance to aerosol administration via mask has been reported in up to 49% of pediatric patients reducing inhaled aerosol to negligible levels.…”

Salbutamol and ipratropium by inhaler is superior to nebulizer in children with severe acute asthma exacerbation: Randomized clinical trial

“…Most guidelines and recent reviews recommend the use of salbutamol by MDI instead of by nebulizer for moderate‐severe asthma exacerbation, but for severe acute asthma exacerbation when oxygen is needed the guidelines recommend the use of a nebulizer. The main reason is the necessity to use oxygen by nebulizer to avoid hypoxemia.…”

G Protein–Coupled Receptors in Asthma Therapy: Pharmacology and Drug Action

“…Albuterol and levalbuterol are both b 2 -adrenergic receptor agonists. Albuterol became commercially available in 1969 and is still used as a highly effective rescue therapy today (Pollock et al, 2017). These medicines function by a similar mechanism of action as LABAs, but with a shorter duration of action.…”

“…The commonly used SAMAs are ipratropium and oxitropium. They are derivatives of the nonspecific muscarinic antagonist atropine, which acts by inhibiting the signaling of MRs to relax smooth muscles (Albertson et al, 2015;Pollock et al, 2017). They can also be used in combination with SABAs, such as albuterol or fenoterol, for increasing the efficacy over monotherapy (Bryant and Rogers, 1990;Nishi et al, 1993;Donohue et al, 2016).…”