Symptomatic Improvement Following Emergency Department Management of Asthma: A Pilot Study of Intramuscular Dexamethasone Versus Oral Prednisone

Abstract

Systemic corticosteroid therapy is an established adjunct to beta-adrenergic medications in acute exacerbations of asthma. To date, no study has defined the role of long-acting intramuscular preparations of corticosteroids in pediatric patients with asthma. A pilot study was conducted to prospectively compare symptomatic improvement following a single injection of intramuscular dexamethasone (IMD) to a 3-day regimen of oral prednisone (OP) for children with mild to moderate wheezing episodes that are responsive to nebulized medications in the Pediatric Emergency Department (PED). The following children presenting with acute exacerbations of asthma to the PED were eligible for enrollment: age 3-16 years; more than two prior wheezing episodes; mild to moderate wheezing; and oxygen saturation 95% or more in room air. The study patients were randomly assigned to receive either IMD (n = 21) or OP (n = 21) in addition to a standardized treatment regimen of nebulized albuterol. All of the children were clinically rated for wheezing severity by the Pulmonary Index (PI) score at regular intervals during the study. Discharge home was based on clinical improvement during treatment in the PED; patients who were admitted to the hospital were removed from the study. Follow-up was conducted the fifth day after discharge from the ED either by clinic visit or by telephone. Patients were assessed for symptomatic improvement and relapse or clinical deterioration during the study period by a clinician blinded to group assignment. Forty-two children participated in this pilot study. There were no significant differences between the IMD and OP groups for gender or age. Mean ages were: 82 months (SD 46 months), IMD group; 63 months (SD 36 months), OP group. Clinical progress (based on PI) with treatment in the PED was the same in both groups: pretreatment median, PI = 6; PED discharge median, PI = 2. None of the study patients were hospitalized during the follow-up period, and all reported symptomatic improvement since initial treatment. The data of this pilot study suggest that IMD may be a feasible alternative to OP for treatment of acute wheezing episodes in children with asthma. IMD provides sufficient treatment to prevent clinical deterioration within 5 days after initial therapy for mild to moderate pediatric exacerbations of asthma that are responsive to nebulized medications.

A Comparison of Oral Dexamethasone With Oral Prednisone in Pediatric Asthma Exacerbations Treated in the Emergency Department

“…[16][17][18] More recently, 2 studies, Qureshi et al 8 and Altamimi et al, 9 evaluated the efficacy of oral dexamethasone. Our findings were similar to these 2 recent studies.…”

Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis

“…Application of inclusion and exclusion criteria resulted in 6 studies that were included in our analysis (Fig 1). [11][12][13][14][15][16] All of the included studies were performed in EDs and had a mean of 171 participants (range 15-272). All studies but one (Gordon et al 12 ) defined relapse as an unplanned clinic visit, return ED visit, or an unplanned hospital admission related to their initial asthma exacerbation.…”

“…All studies but one (Gordon et al 12 ) defined relapse as an unplanned clinic visit, return ED visit, or an unplanned hospital admission related to their initial asthma exacerbation. Dexamethasone was given as a single IM dose in 3 studies, 12,14,15 as a single oral dose in 1 study, 11 and as multiple oral doses in 2 studies 13,16 (Table1). Included studies were from the United States (n = 5) and Canada (n = 1).…”

“…The 4 studies that reported 5-day follow-up relapse rates all used a single dose of IM or PO dexamethasone. 11,12,14,15 Five days was the most common follow-up duration and is the most clinically relevant period in which to detect treatment failure. This is supported by the fact that 5-day courses of oral corticosteroids have not been shown to be superior to 3-day courses for outpatient management of children with acute exacerbations.…”

Is Dexamethasone an Effective Alternative to Oral Prednisone in the Treatment of Pediatric Asthma Exacerbations?

“…Klig et al 26 performed a prospective, randomized pilot study comparing a single dose of IM dexamethasone with 3 days of PO prednisone in children with a history of >2 wheezing episodes and a mild to moderate asthma exacerbation based on a pulmonary index score. Age-and gendermatched patients were randomized to receive the medications.…”