Variation in treatment of acute childhood wheeze in emergency departments of the United Kingdom and Ireland: an international survey of clinician practice

Lyttle, Mark D; O’Sullivan, Ronan; Doull, Iolo; Hartshorn, Stuart; Morris, Ian; Powell, Colin

doi:10.1136/archdischild-2014-306591

Cited by 32 publications

(35 citation statements)

References 23 publications

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“…A recent survey of practice among EDs in the UK identified variations in the management of acute asthma in children (3). While most clinicians surveyed used inhaled salbutamol as first-line therapy, other practices did not reflect the results of this overview.…”

Section: Discussionmentioning

confidence: 99%

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

Pollock

Sinha

Hartling

et al. 2016

Allergy

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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 ...

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Section: Discussionmentioning

confidence: 99%

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

Pollock

Sinha

Hartling

et al. 2016

Allergy

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“…There is no clear agreement about doses of salbutamol required by any route with individual centres reporting sixfold differences in the doses of inhaled salbutamol and around 10-fold variations in the doses of intravenous salbutamol recommended 19. Our own experience is that care is necessary when using intravenous salbutamol as it is incredibly easy to exceed the recommended adult doses using many of the widely available paediatric protocols.…”

Section: Pharmacology Of Salbutamol: An Abcd Approachmentioning

confidence: 99%

“…Wide variation in the treatment of acute wheeze exists in the UK, despite clear national guidelines, which reflects the relative lack of evidence in what constitutes best practice in paediatric populations 19. Salbutamol should be used primarily to treat bronchospasm in acute exacerbations of asthma.…”

Section: Pharmacology Of Salbutamol: An Abcd Approachmentioning

confidence: 99%

Salbutamol in paediatrics: pharmacology, prescribing and controversies

Andrzejowski

Carroll

2016

Arch Dis Child Educ Pract Ed

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Salbutamol has become a key drug in respiratory medicine since it was first developed by Sir David Jack et al in 1968, 5000 years after the β agonist ephedrine was first used in its raw form, as the Ma Huang herb in Chinese medicine to treat asthma. It is one of the most commonly encountered medicines in paediatric practice and the authors have found that an understanding of its pharmacology in clinical practice is incredibly helpful. In this article, we discuss its pharmacology and pharmacodynamics, practical prescribing points and some unresolved issues surrounding its use, which should serve to provide an essential working knowledge for the busy paediatrician.

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“…These aim to present recommendations to improve asthma care based on best available evidence, but there are several areas in which the evidence base is small or absent. This inevitably leads to variation in practice throughout the asthma pathway, as demonstrated in recent work from Paediatric Emergency Research in the UK & Ireland5 6 in which the greatest variations were at the severe end of the spectrum; multiple dosages and regimens for intravenous therapy were a key finding, though variation also existed in inhaled and oral therapies, assessment and other supportive therapies. These variations can and should be used to inform the future research agenda in childhood asthma, but it is also essential to consider what we could be doing better today, especially given the striking variation in admission rates and length of stay evidenced in the NHS Atlas of Variation in Healthcare 7.…”

Section: Unresolved Controversiesmentioning

confidence: 99%

British guideline on the management of asthma: SIGN Clinical Guideline 141, 2014

James

Lyttle

2016

Arch Dis Child Educ Pract Ed

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Variation in treatment of acute childhood wheeze in emergency departments of the United Kingdom and Ireland: an international survey of clinician practice

Cited by 32 publications

References 23 publications

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

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

Salbutamol in paediatrics: pharmacology, prescribing and controversies

British guideline on the management of asthma: SIGN Clinical Guideline 141, 2014

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