Antiasthmatic therapy in children

Drug therapy approaches in the treatment of acute severe asthma in hospitalised children

Acute severe paediatric asthma remains a serious and debilitating disease throughout the world. The incidence and mortality from asthma continue to increase. Early, effective and aggressive outpatient therapy is essential in reducing symptoms and preventing life-threatening progression. When complications occur or when the disease progresses to incipient respiratory failure, these children need to be managed in a continuous care facility where aggressive and potentially dangerous interventions can be safely instituted to reverse persistent bronchospasm. The primary drugs for acute severe asthma include oxygen, corticosteroids, salbutamol (albuterol) and anticholinergics. Second-line drugs include heliox, magnesium sulfate, ketamine and inhalational anaesthetics. Future therapies may include furosemide, leukotriene modifiers, antihistamines and phosphodiesterase inhibitors. This review attempts to explore the multitude of medications available with emphasis on pharmacology and pathophysiology.

Severe acute asthma in a community hospital pediatric intensive care unit: a ten years' experience

BACKGROUND

The clinical literature on the incidence and subsequent mortality of asthma has come primarily from the experiences of large tertiary referral centers, particularly in Western Europe and North America. Consequently, very little has been published on the incidence, management, and outcome of asthma in smaller, community-based intensive care units.

OBJECTIVES

The purpose of this study was to explore the course and outcome of children with acute severe asthma treated within a community hospital PICU compared with those described in the literature from larger tertiary referral centers.

DESIGN

A retrospective analysis of 49 asthmatic children admitted to the Pediatric Intensive Care Unit (PICU) over a 10-year period was performed.

MEASUREMENTS AND RESULTS

The mean age was 5.2 years (range 2 months to 16 years), and the male:female ratio was 3:1. Duration of symptoms prior to admission to hospital was less than 24 hours in 60.4% of the patients. The majority of patients was not treated with either inhaled or oral steroids before admission. Drugs used in the PICU included nebulized beta2-agonists, theophylline, steroids, intravenous salbutamol, and intravenous isoproterenol. Although a pharmacologic approach was successful in the majority of patients, intubation and mechanical ventilation were necessary for progressive hypercapnea, exhaustion, and cardiorespiratory arrest in 11/49 of these patients. The average stay in the ICU for our patient group was 2.4 days. Intubated patients had a mean average stay of 3.5 days. Two patients had pneumothorax related to positive pressure ventilation, requiring chest tube insertion for drainage. There were no deaths among the 49 patients admitted to our PICU.

CONCLUSIONS

These data show that for acute severe asthma, outcome is comparable in a community PICU to a tertiary referral institution. We conclude that early ICU admission along with close monitoring is important in reducing morbidity and mortality in children with severe asthma.

Comparative study of budesonide as a nebulized suspension vs pressurized metered-dose inhaler in adult asthmatics

The study objective was to compare the effect of budesonide administered as a nebulized suspension as compared to a spray with a spacer in adult asthmatics. In a double-blind, double-dummy crossover study, 26 adult patients with moderately severe unstable asthma were randomized to three 4-week treatment periods with budesonide 0.8 mg b.i.d. administered by a pressurized metered-dose inhaler (pMDI) with spacer (Nebuhaler) and budesonide 1 mg and 4 mg b.i.d. administered by a Pari Inhalier Boy jet nebulizer. The nebulizer was activated only during inspiration. The total mass output was similar from the two devices but their fraction of small particles differed by a factor of 2 in favour of pMDI. Effect was evaluated from daily home measurements of peak expiratory flow (PEF), need of beta 2-agonist and symptom scores. Plasma cortisol and budesonide levels were measured in a subgroup of 10 patients. A consistent trend showed the nebulizer treatment to be at least as efficient as the pMDI plus spacer treatment. In actual fact, the apparent order of effect was: 4 mg nebulized suspension treatment > or = 1 mg nebulized suspension treatment > or = 0.8 mg pMDI with spacer treatment. Plasma budesonide and plasma cortisol also exhibited dose-related levels independent of device. The adverse effects reported appeared to be related to the dose rather than delivery device. Accordingly, the effect was related to total mass output, rather than to the small particle fraction of the budesonide aerosol. These results attest to the efficiency of jet-nebulized budesonide suspension, and indicate nebulized budesonide to be equipotent to standard budesonide therapy delivered by pMDI with Nebuhaler, provided nebulization is synchronized with inspiration and no loss of aerosol occurs during expiration.

Treatment of critical status asthmaticus in children

Status asthmaticus is complex in its etiology and pathophysiology and may be associated with significant morbidity and mortality. Although there are many therapeutic options, specific inhaled beta 2-agonists, corticosteroids, and oxygen remain the mainstay of therapy. Several new drugs and some older drugs are being used in management; their exact role in treatment at present, however, relies largely on personal preferences. Innovative methods of providing ventilatory support are also emerging. What is quite clear is the fact that involvement of specialists (pulmonologists and intensivists) early in the course of severe status asthmaticus is needed to ensure optimal management and possibly favorable outcomes.

Acute asthma. Single dose oral steroids in paediatric community clinics

The treatment of an acute asthma attack usually includes bronchodilators and often steroids. We studied 70 children who were randomly assigned to receive either single dose steroids (oral prednisone: 20-40 mg) or placebo on a double blind basis. The time course of the observation was 72 h. We demonstrate that a single dose of steroids, given orally in paediatric community clinics during an acute mild to moderate asthma attack, significantly improves the patient's course; deterioration was prevented, symptoms were relieved faster, and hospitalization was not required. We encourage paediatricians in the ambulatory clinics to follow this treatment modality and to give, in addition to other conventional therapy, a single oral dose of steroids early in the asthma attack, in order to relieve and shorten the child's distress.

Changes in the treatment of wheezing children in the emergency department

This study prospectively examined the pharmacologic treatment of all wheezing children presenting to a pediatric emergency department from December 1987 to September 1991 (10,091 cases). There were increasing trends in rate of hospitalization, use of oxygen saturation measurements, use of corticosteroids and beta agents at discharge, and use of aerosolized bronchodilators administered in the emergency department. This cohort shows decreasing trends in use of theophylline and the use of subcutaneous bronchodilators administered in the emergency department. Increasing patient severity could not be confirmed in this cohort. The increase in use of corticosteroids in wheezing children is well supported in the literature. The use of theophylline appears to have significantly declined while there is still some controversy over its recommendations in the literature.

Chronic cough in children

Chronic cough in children is a frequent complaint seen by the primary health care provider. Although many of these coughs spontaneously resolve, some are caused by a more serious process and require further attention. Selecting those patients who will benefit from a more extensive evaluation can be a difficult challenge. An overview is provided that emphasizes a systematic approach to the diagnosis and management of chronic cough.