Treatment patterns and frequency of key outcomes in acute severe asthma in children: a Paediatric Research in Emergency Departments International Collaborative (PREDICT) multicentre cohort study

Abstract

RationaleSevere acute paediatric asthma may require treatment escalation beyond systemic corticosteroids, inhaled bronchodilators and low-flow oxygen. Current large asthma datasets report parenteral therapy only.ObjectivesTo identify the use and type of escalation of treatment in children presenting to hospital with acute severe asthma.MethodsRetrospective cohort study of children with an emergency department diagnosis of asthma or wheeze at 18 Australian and New Zealand hospitals. The main outcomes were use and type of escalation treatment (defined as any of intensive care unit admission, nebulised magnesium, respiratory support or parenteral bronchodilator treatment) and hospital length of stay (LOS).Measurements and main resultsOf 14 029 children (median age 3 (IQR 1–3) years; 62.9% male), 1020 (7.3%, 95% CI 6.9% to 7.7%) had treatment escalation. Children with treatment escalation had a longer LOS (44.2 hours, IQR 27.3–63.2 hours) than children without escalation 6.7 hours, IQR 3.5–16.3 hours; p<0.001). The most common treatment escalations were respiratory support alone (400; 2.9%, 95% CI 2.6% to 3.1%), parenteral bronchodilator treatment alone (380; 2.7%, 95% CI 2.5% to 3.0%) and both respiratory support and parenteral bronchodilator treatment (209; 1.5%, 95% CI 1.3% to 1.7%). Respiratory support was predominantly nasal high-flow therapy (99.0%). The most common intravenous medication regimens were: magnesium alone (50.4%), magnesium and aminophylline (24.6%) and magnesium and salbutamol (10.0%).ConclusionsOverall, 7.3% children with acute severe asthma received some form of escalated treatment, with 4.2% receiving parenteral bronchodilators and 4.3% respiratory support. There is wide variation treatment escalation.

Analysis of guideline recommendations for treatment of asthma exacerbations in children: a Pediatric Emergency Research Networks (PERN) study

“…It is therefore apparent, that existing recommendations for the best management of severe acute paediatric asthma are currently based on suboptimal evidence with inconsistent, inconclusive or absent results and a paucity of adequately powered randomised controlled trials. Large observational studies have identified that some outcomes (such as intubation) are likely too rare to be used as primary outcome measures, and practice-changing studies will require collaboration between a large number of centres 37. There remains an urgent need for a global agreement regarding optimised trial designs with the most relevant core outcome measures to provide better evidence to inform future clinical practice 19…”

“…Large observational studies have identified that some outcomes (such as intubation) are likely too rare to be used as primary outcome measures, and practice-changing studies will require collaboration between a large number of centres. [38] There remains an urgent need for a global agreement regarding optimized trial designs with the most relevant core outcome measures to provide better evidence to inform future clinical practice. [19] The overall guideline quality was moderate in our study, with high ratings for clarity of presentation, scope and purpose.…”

Acute paediatric asthma treatment in the prehospital setting: a retrospective observational study

“…A recent large study described in-hospital management of acute asthma exacerbations in Australia and New Zealand. In 14 029 children, there was a higher overall rates of escalated therapy (7.3% overall, with 4.2% receiving parenteral bronchodilators and 4.3% respiratory support) 12. A common indication for escalation of care is failure to adequately respond to first-line therapy.…”

International perspective on research priorities and outcome measures of importance in the care of children with acute exacerbations of asthma: a qualitative interview study

“…[2][3][4] While many children have mild to moderate exacerbations and are discharged home, a recently published study of 14 029 children presenting to Australasian EDs found that 36% of children with acute asthma are admitted to hospital, with 1.1% requiring paediatric intensive care unit admission (PICU). 5 In addition, recent studies document increasing PICU admission for severe acute asthma worldwide. 4 Despite this concerning scenario, the evidence base informing treatments for these high-risk patients with severe presentations is weak.…”