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Kaviany P, Shah A. Current Practices in Pediatric Asthma Care. Clin Chest Med 2024; 45:611-623. [PMID: 39069325 DOI: 10.1016/j.ccm.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
This article is a comprehensive review of the latest knowledge and developments on pediatric asthma. It serves as a guide for general practitioners and subspecialists who treat asthma. The pathophysiology and critical features of asthma that should be addressed and the latest therapies available are discussed. The areas where further investigation is needed are also highlighted.
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Affiliation(s)
- Parisa Kaviany
- Division of Pulmonary & Sleep Medicine, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Avenue Northwest, Washington, DC 20010, USA
| | - Avani Shah
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 155 East Superior Street, Box #48, Chicago, IL 60611, USA.
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de Havilland A, Hariharan G, Puvvadi R. Is intravenous magnesium sulphate safe to be administered outside the critical care setting? J Paediatr Child Health 2022; 58:924-928. [PMID: 35338747 DOI: 10.1111/jpc.15951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 02/10/2022] [Accepted: 03/06/2022] [Indexed: 11/30/2022]
Abstract
AIM To review current evidence regarding the safety of intravenous bolus magnesium sulphate for the treatment of children with acute severe asthma in the non-critical care setting. METHODS MEDLINE via Ovid, Embase and the Cochrane Library were searched for relevant articles. RESULTS Four hundred and eighteen articles were identified during the initial search after removal of duplicates. Eighty full-text articles were selected for review and 16 included as relevant to the clinical question. CONCLUSIONS Current evidence suggests that bolus intravenous magnesium sulphate is safe to be administered in non-critical care settings provided that line of sight nursing and cardiorespiratory monitoring are available.
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Affiliation(s)
- Amanda de Havilland
- JCU College of Medicine and Dentistry, Mackay Base Hospital, Mackay, Queensland, United States
| | - Gopakumar Hariharan
- Department of Child and Adolescent Health Unit, James Cook University, Mackay Base Hospital, Mackay, Queensland, United States
| | - Ramaa Puvvadi
- Department of Paediatrics, Townsville University Hospital, Townsville, Queensland, United States
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Johnson PN, Drury AS, Gupta N. Continuous Magnesium Sulfate Infusions for Status Asthmaticus in Children: A Systematic Review. Front Pediatr 2022; 10:853574. [PMID: 35391743 PMCID: PMC8983002 DOI: 10.3389/fped.2022.853574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Magnesium sulfate is a second-tier therapy for asthma exacerbations in children; guidelines recommend a single-dose to improve pulmonary function and decrease the odds of admission to the in-patient setting. However, many clinicians utilize prolonged magnesium sulfate infusions for children with refractory asthma. The purpose of this review is to describe the efficacy and safety of magnesium sulfate infusions administered over ≥ 1 h in children with status asthmaticus. METHODS Medline was searched using the keywords "magnesium sulfate" and "children." Articles evaluating the use of magnesium sulfate infusions for ≥1 h published between 1946 and August 2021 were included. Published abstracts were not included because of lack of essential details. All articles were screened by two reviewers. RESULTS Eight reports including 447 children were included. The magnesium regimens evaluated included magnesium delivered over 1 h (n = 148; 33.1%), over 4-5 h (n = 105; 23.5%), and over >24 h (n = 194; 43.4%). Majority of patients received a bolus dose of 25-75 mg/kg/dose prior to initiation of a prolonged infusion (n = 299; 66.9%). For the patients receiving magnesium infusions over 4-5 h, the dosing regimen varied between 40 and 50 mg/kg/h. For those receiving magnesium infusions >24 h, the dosing varied between 18.4 and 25 mg/kg/h for a duration between 53.4 and 177.5 h. Only three reports including 186 patients (41.6%) included an evaluation of clinical outcomes including evaluation of lung function parameters, reduction in PICU transfers, and/or decrease in emergency department length of stay. Five reports including 261 patients (58.4%) evaluated magnesium serum concentrations. In most reports, the goal concentrations were between 4 and 6 mg/dL. Only 3 (1.1%) out of the 261 patients had supratherapeutic magnesium concentrations. The only reports finding adverse events attributed to magnesium were noted in those receiving infusions for >24 h. Clinically significant adverse events included hypotension (n = 74; 16.6%), nausea/vomiting (n = 35; 7.8%), mild muscle weakness (n = 22; 4.9%), flushing (n = 10; 2.2%), and sedation (n = 2; 0.4%). CONCLUSION Significant variability was noted in magnesium dosing regimens, with most children receiving magnesium infusions over >4 h. Most reports did not assess clinical outcomes. Until future research is conducted, the use of prolonged magnesium sulfate infusions should be reserved for refractory asthma therapy.
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Affiliation(s)
- Peter N Johnson
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Anna Sahlstrom Drury
- Department of Pharmacy, University of Kentucky Chandler Medical Center, Lexington, KY, United States
| | - Neha Gupta
- Division of Critical Care Medicine, Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, OK, United States
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Taher KW, Johnson PN, Miller JL, Neely SB, Gupta N. Efficacy and Safety of Prolonged Magnesium Sulfate Infusions in Children With Refractory Status Asthmaticus. Front Pediatr 2022; 10:860921. [PMID: 35757130 PMCID: PMC9218095 DOI: 10.3389/fped.2022.860921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES There is a paucity of data on the use of intravenous magnesium sulfate infusion in children with refractory status asthmaticus. The purpose of this study was to evaluate the efficacy and safety of prolonged magnesium sulfate infusion as an advanced therapy. METHODS This is a single center retrospective study of children admitted to our pediatric intensive care unit (PICU) with status asthmaticus requiring continuous albuterol. Treatment group included patients receiving magnesium for ≥4 h and control group included those on other therapies only. Patients were matched 1:4 based on age, sex, obesity, pediatric index of mortality III and pediatric risk of mortality III scores. Primary outcomes included PICU length of stay (LOS) and mechanical ventilation (MV) requirement. Secondary outcomes included mortality, extracorporeal membrane oxygenation (ECMO) requirement, analyses of factors associated with PICU LOS and MV requirement and safety of magnesium infusion. Logistic and linear regressions were employed to determine factors associated with MV requirement and PICU LOS, respectively. RESULTS Treatment and control groups included 27 and 108 patients, respectively. Median initial infusion rate was 15 mg/kg/hour, with median duration of 28 h. There was no difference in the MV requirement between the treatment and control groups [7 (25.9%) vs. 20 patients (18.5%), p = 0.39]. Median PICU LOS and ECMO use were significantly higher in treatment vs. control group [(3.63 vs. 1.09 days, p < 0.01) and (11.1 vs. 0%, p < 0.01), respectively]. No mortality difference was noted. On regression analysis, patients receiving ketamine and higher prednisone equivalent dosing had higher odds of MV requirement [OR 19.29 (95% CI 5.40-68.88), p < 0.01 and 1.099 (95% CI 1.03-1.17), p < 0.01, respectively]. Each mg/kg increase in prednisone equivalent dosing corresponded to an increase in PICU LOS by 0.13 days (95% CI 0.096-0.160, p < 0.01). Magnesium infusions were not associated with lower MV requirement or lower PICU LOS after controlling for covariates. Fourteen (51.9%) patients in the treatment group had an adverse event, hypotension being the most common. CONCLUSION Magnesium sulfate infusions were not associated with MV requirement, PICU LOS or mortality.
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Affiliation(s)
- Khalid W Taher
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Jamie L Miller
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Stephen B Neely
- Office of Instruction, Assessment, and Faculty/Staff Development, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Neha Gupta
- Department of Pediatrics, Division of Critical Care Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK, United States
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Antoon JW, Hall M, Mittal V, Parikh K, Morse RB, Teufel RJ, Hogan AH, Shah SS, Kenyon CC. Intravenous Magnesium and Hospital Outcomes in Children Hospitalized With Asthma. Hosp Pediatr 2021; 11:785-793. [PMID: 34210764 DOI: 10.1542/hpeds.2020-004770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Use of intravenous magnesium (IVMg) for childhood asthma exacerbations has increased significantly in the last decade. Emergency department administration of IVMg has been shown to reduce asthma hospitalization, yet most children receiving IVMg in the emergency department are subsequently hospitalized. Our objective with the study was to examine hospital outcomes of children given IVMg for asthma exacerbations. METHODS We conducted a retrospective cohort study using data from the Pediatric Health Information System. We used propensity score matching to compare children who received IVMg on the first day of hospitalization with those who did not. Primary outcomes were initiation and duration of noninvasive positive pressure ventilation. Secondary outcomes included mechanical ventilation (MV) initiation, duration of MV, length of stay, and subsequent tertiary medication use. Primary analysis was restricted to children admitted to nonintensive care inpatient units. RESULTS Overall, 91 309 hospitalizations met inclusion criteria. IVMg was administered in 25 882 (28.4%) children. After propensity score matching, IVMg was not significantly associated with lower initiation (adjusted odds ratio 0.88; 95% confidence interval [CI] 0.74-1.05) or shorter duration of noninvasive positive pressure ventilation (rate ratio 0.94; 95% CI 0.87-1.02). Similarly, no significant associations were seen for MV initiation, MV duration, or length of stay. IVMg was associated with lower subsequent tertiary medication use (adjusted odds ratio 0.66; 95% CI 0.60-0.72). However, the association was lost when ipratropium was removed from the tertiary medication definition. CONCLUSIONS IVMg administration was not significantly associated with improved hospital outcomes. Further study is needed to inform the optimal indications and timing of magnesium use during hospitalization.
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Affiliation(s)
- James W Antoon
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee .,Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Vineeta Mittal
- Division of Pediatric Hospital Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kavita Parikh
- Hospitalist Division, Children's National Medical Center and School of Medicine, George Washington University, Washington, District of Columbia
| | | | - Ronald J Teufel
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Alexander H Hogan
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Chén C Kenyon
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia and School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Mittal V, Hall M, Antoon J, Gold J, Kenyon C, Parikh K, Morse R, Quinonez R, Teufel RJ, Shah SS. Trends in Intravenous Magnesium Use and Outcomes for Status Asthmaticus in Children's Hospitals from 2010 to 2017. J Hosp Med 2020; 15:403-406. [PMID: 32584247 PMCID: PMC7402601 DOI: 10.12788/jhm.3405] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 03/04/2020] [Indexed: 11/20/2022]
Abstract
Intravenous (IV) magnesium is used as an adjunct therapy in management of status asthmaticus with a goal of reducing intubation rate. A recent review suggests that IV magnesium use in status asthmaticus reduces admission rates. This is contrary to the observation of practicing emergency room physicians. The goal of this study was to assess trends in IV magnesium use for status asthmaticus in US children's hospitals over 8 years through a retrospective analysis of children younger than 18 years using the Pediatric Health Information System database. Outcomes were IV magnesium use, inpatient and intensive care unit admission rate, geometric mean length of stay, and 7-day all-cause readmission rate. IV magnesium use for asthma hospitalization more than doubled over 8 years (17% vs. 36%; P < .001). Yearly trends were not significantly associated with hospital or intensive care unit admission rate or 7-day all-cause readmissions, although length of stay was reduced (P < .001).
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Affiliation(s)
- Vineeta Mittal
- Division of Pediatric Hospital Medicine, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas
- Department of Pediatrics, Children’s Health System, Dallas, Texas
- Corresponding Author: Vineeta Mittal, MD, MBA; ; Telephone: 214-456-5527; Twitter: @Vmittal
| | - Matt Hall
- Informatics, Children’s Hospital Association, Lenexa, Kansas
| | - James Antoon
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine
| | - Jessica Gold
- Pediatrics, Stanford University School of Medicine/Lucile Packard Children’s Hospital, San Mateo, California
| | - Chen Kenyon
- Department of Pediatrics, Children’s Hospital of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kavita Parikh
- Hospitalist Division, Children’s National Medical Center, Washington, District of Columbia
- Hospitalist Division, George Washington School of Medicine, Washington, District of Columbia
| | - Rustin Morse
- Department of Quality and Safety, Children’s Health System of Texas, Dallas, Texas
| | - Ricardo Quinonez
- Division of Pediatric Hospital Medicine, Texas Children’s Hospital, Houston, Texas
- Division of Pediatric Hospital Medicine, Baylor College of Medicine, Houston, Texas
| | - Ronald J Teufel
- Departemnt of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Samir S Shah
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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Özdemir A, Doğruel D. Efficacy of Magnesium Sulfate Treatment in Children with Acute Asthma. Med Princ Pract 2020; 29:292-298. [PMID: 32069472 PMCID: PMC7315220 DOI: 10.1159/000506595] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/17/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Systemic administration of magnesium sulfate (MgSO4) has been proposed as a treatment for pediatric patients with acute asthma. However, previous trials show mixed results and uncertain evidence of benefit. The aim of the study was to ascertain whether intravenous (IV) MgSO4 improves lung function parameters in children with acute asthma. METHODS This was a prospective clinical trial. All patients with acute asthma received 40-50 mg/kg or maximum 1,500 mg (>30 kg) of single dose IV MgSO4, administered over 60 min. Spirometry was conducted before and 15 min after MgSO4 infusion. RESULTS One hundred and fifteen children aged 6 to 17 years presenting with acute asthma and FEV1 between 40% and 75% of predicted were included. Then, the patients were classified into 2 groups; mild asthma attack (FEV1 ranged from 60% to 75%; n = 50) or moderate asthma attack (FEV1 ranged from 40% to 59%; n = 65). The baseline characteristics were similar in both groups. The mean percent predicted pre and post values for FEV1/FVC ratio (mild group: 82.59 ± 9.46 vs. 85.06 ± 8.95; moderate group: 77.31 ± 11.17 vs. 79.99 ± 11.77), FEV1 (mild group: 67.14 ± 4.99 vs. 72.29 ± 8.05; moderate group: 48.50 ± 6.81 vs. 53.78 ± 9.81), PEF (mild group: 65.49 ± 12.32 vs. 71.37 ± 12.96; moderate group: 47.56 ± 11.78 vs. 51.97 ± 13.98), and FEF25-75 (mild group: 58.20 ± 12.24 vs. 66.57 ± 16.95; moderate group: 37.77 ± 11.37 vs. 43.41 ± 14.19) showed a statistically significant (p < 0.05 for all) bronchodilator effect after MgSO4 infusion in both groups with few side effects. CONCLUSION Administration of IV MgSO4 was associated with improved pulmonary function in children with acute asthma.
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Affiliation(s)
- Ali Özdemir
- Pediatric Pulmonary Section, Department of Pediatrics, Mersin City Training and Research Hospital, Mersin, Turkey,
| | - Dilek Doğruel
- Pediatric Allergy Section, Department of Pediatrics, University of Cukurova, Adana, Turkey
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