Dexamethasone for acute asthma exacerbations in children: a meta-analysis

Outcomes of a dexamethasone-prednisone combination treatment course for status asthmaticus

OBJECTIVES

Dexamethasone has become the standard of care for pediatric patients with status asthmaticus in the emergency department (ED) setting. Inpatient providers often must decide between continuing the second dose of dexamethasone or transitioning to prednisone. The effectiveness of receiving dexamethasone followed by prednisone (combination therapy) compared to only prednisone or dexamethasone remains unclear. This study compares patient characteristics and ED reutilization/hospital readmission outcomes of dexamethasone, prednisone, and combination therapy for inpatient asthma management.

METHODS

A retrospective study was conducted at our tertiary children's hospital of children aged 2 to 18 years hospitalized between March 2016 and December 2018 with a primary discharge diagnosis of asthma, reactive airway disease, or bronchospasm. The differences between steroid groups were compared using Fisher's exact or Chi-square tests for categorical variables, and a Kruskal-Wallis test for continuous variables. A multivariable logistic regression was performed to analyze ED reutilization and hospital readmission rates.

RESULTS

1697 subjects met inclusion criteria. 115 (6.8%) patients received dexamethasone, 597 (35.2%) received prednisone, and 985 (58.0%) received combination therapy. Patients prescribed combination therapy had a lower exacerbation severity than patients prescribed prednisone, but higher severity than patients prescribed dexamethasone (p < .001, p = .001, respectively). Dexamethasone and combination therapy were not associated with increased 30-day ED reutilization/hospital readmissions compared to prednisone (p > .05).

CONCLUSIONS

In our study, most patients hospitalized for status asthmaticus received combination therapy. Despite the differences in severity between steroid groups, outcomes of combination therapy and dexamethasone monotherapy, as measured by frequency of ED reutilizations/hospital readmissions, are comparable to prednisone monotherapy.

Pediatric pulmonology year in review-Pediatric pulmonary critical care

Pediatric pulmonary critical care literature has continued to grow in recent years. Our aim in this review is to narrowly focus on publications providing clinically-relevant advances in pediatric pulmonary critical care in 2023.

Impact of a discharge prescription for dexamethasone on outcomes of children treated in the emergency department for acute asthma exacerbations

OBJECTIVE

To evaluate dexamethasone prescribing practices, patient adherence, and outcomes by dosing regimen in children with acute asthma discharged from the emergency department (ED).

STUDY DESIGN

Prospective study of children 2-18 years treated with dexamethasone for acute asthma prior to discharge from an urban, tertiary care ED between 2018 and 2022. Demographics, clinical characteristics, ED treatment, and discharge prescriptions were collected via chart review. The exposure was discharge prescription (additional dose) versus no discharge prescription for dexamethasone. The primary outcome was treatment failure, defined as return ED visit, unplanned primary care visit, and/or ongoing bronchodilator use. Secondary outcomes included medication adherence, symptom persistence, quality-of-life, and school/work absenteeism. Outcomes were assessed by telephone 7-10 days after discharge.

RESULTS

564 subjects were enrolled; 338 caregivers (60%) completed follow-up. Children were a median age 7 years, 30% Black or African American, 49% Hispanic, and 79% had public insurance. A discharge prescription for dexamethasone was written for 482 (86%) children and was significantly associated with exacerbation severity, number of combined albuterol/ipratropium treatments, and longer length of stay. There was no difference in treatment failure between the discharge prescription and no discharge prescription groups (RR 0.87; 0.67, 1.12), including after adjusting for potential confounders; there was no difference between groups in secondary outcomes.

CONCLUSIONS

Prescription for an additional dexamethasone dose was not associated with reduced treatment failure or improved outcomes for children with acute asthma discharged from the ED. Single, ED-dose of dexamethasone prior to discharge may be sufficient for children with mild to moderate asthma exacerbations.

Drug repurposing for personalized medicine

Personalized medicine has emerged as a revolutionary approach to healthcare in the 21st century. By understanding a patient's unique genetic and biological characteristics, it aims to tailor treatments specifically to the individual. This approach takes into account factors such as an individual's lifestyle, genetic makeup, and environmental factors to provide targeted therapies that have the potential to be more effective and lower the risk of side reactions or ineffective treatments. It is a paradigm shift from the traditional "one size fits all" approach in medicine, where patients with similar symptoms or diagnoses receive the same standard treatments regardless of their differences. It leads to improved clinical outcomes and more efficient use of healthcare resources. Drug repurposing is a strategy that uses existing drugs for new indications and aims to take advantage of the known safety profiles, pharmacokinetics, and mechanisms of action of these drugs to accelerate the development process. Precision medicine may undergo a revolutionary change as a result, enabling the rapid development of novel treatment plans utilizing drugs that traditional methods would not otherwise link to. In this chapter, we have focused on a few strategies wherein drug repurposing has shown great success for precision medicine. The approach is particularly useful in oncology as there are many variations induced in the genetic material of cancer patients, so tailored treatment approaches go a long way. We have discussed the cases of breast cancer, glioblastoma and hepatocellular carcinoma. Other than that, we have also looked at drug repurposing approaches in anxiety disorders and COVID-19.

Vandetanib as a prospective anti-inflammatory and anti-contractile agent in asthma

Background: Vandetanib is a small-molecule tyrosine kinase inhibitor. It exerts its therapeutic effects primarily in a range of lung cancers by inhibiting the vascular endothelial growth factor receptor 2. However, it remains unclear whether vandetanib has therapeutic benefits in other lung diseases, particularly asthma. The present study investigated the pioneering use of vandetanib in the treatment of asthma. Methods: In vivo experiments including establishment of an asthma model, measurement of airway resistance measurement and histological analysis were used primarily to confirm the anticontractile and anti-inflammatory effects of vandetanib, while in vitro experiments, including measurement of muscle tension and whole-cell patch-clamp recording, were used to explore the underlying molecular mechanism. Results: In vivo experiments in an asthmatic mouse model showed that vandetanib could significantly alleviate systemic inflammation and a range of airway pathological changes including hypersensitivity, hypersecretion and remodeling. Subsequent in vitro experiments showed that vandetanib was able to relax the precontracted rings of the mouse trachea via calcium mobilization which was regulated by specific ion channels including VDLCC, NSCC, NCX and K+ channels. Conclusions: Taken together, our study demonstrated that vandetanib has both anticontractile and anti-inflammatory properties in the treatment of asthma, which also suggests the feasibility of using vandetanib in the treatment of asthma by reducing abnormal airway contraction and systemic inflammation.

Duloxetine HCl Alleviates Asthma Symptoms by Regulating PI3K/AKT/mTOR and Nrf2/HO-1 Signaling Pathways

Asthma is an inflammatory disease characterized by airway hyperresponsiveness, airway remodeling, and airway inflammation. In recent years, the prevalence of asthma has been increasing steadily and the pathogenesis of asthma varies from person to person. Due to poor compliance or resistance, existing drugs cannot achieve the desired therapeutic effect. Therefore, developing or screening asthma therapeutic drugs with high curative effects, low toxicity, and strong specificity is very urgent. Duloxetine HCl (DUX) is a selective serotonin and norepinephrine reuptake inhibitor, and it was mainly used to treat depression, osteoarthritis, and neuropathic pain. It was also reported that DUX has potential anti-infection, anti-inflammation, analgesic, antioxidative, and other pharmacological effects. However, whether DUX has some effects on asthma remains unknown. In order to investigate it, a series of ex vivo and in vivo experiments, including biological tension tests, patch clamp, histopathological analysis, lung function detection, oxidative stress enzyme activity detection, and molecular biology experiments, were designed in this study. We found that DUX can not only relax high potassium or ACh precontracted tracheal smooth muscle by regulating L-type voltage-dependent Ca2+ channel (L-VDCC) and nonselective cation channel (NSCC) ion channels but also alleviate asthma symptoms through anti-inflammatory and antioxidative response regulated by PI3K/AKT/mTOR and Nrf2/HO-1 signaling pathways. Our data suggests that DUX is expected to become a potential new drug for relieving or treating asthma.

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Effects of Pre-Hospital Dexamethasone Administration on Outcomes of Patients with COPD and Asthma Exacerbation; a Cross-Sectional Study

Introduction

Chronic obstructive pulmonary disease (COPD) and asthma exacerbation are two common emergency situations. This study aimed to investigate the impact of pre-hospital dexamethasone initiation on treatment outcomes of these patients.

Methods

In this retrospective cross-sectional and comparative study, data from the emergency medical service (EMS) care report of patients with a final diagnosis of asthma or COPD, coded with Thailand's emergency medical triage protocol, collected between January 1, 2021, and October 31, 2022, were used. Data on baseline characteristics, emergency department length of stay (ED-LOS), and hospital admission rates were collected from electronic medical records and compared between cases with and without pre-hospital dexamethasone administration by EMS.

Results

200 patients with COPD (n = 93) and asthma (n = 107) exacerbation were enrolled. The dexamethasone-treated group had a lower but statistically non-significant hospital admission rate (71.0% versus 81.0%, absolute difference: -10%, 95% confidence interval (CI): -21.76, 1.76; p = 0.100). In patients with asthma, the dexamethasone-treated had lower median ED-LOS time (235 (IQR: 165.5-349.5) versus 322 (IQR: 238-404) minutes; p = 0.003). Dexamethasone-treated asthma patients had lower but statistically non-significant hospital admission rates (60.4% versus 78.0%, absolute difference: -17.55%, 95% CI: -34.96, -0.14; p = 0.510). In COPD patients the dexamethasone-treated and untreated groups had non-significantly lower hospital admission rates (80.8% versus 85.40%, absolute difference: -4.60%, 95% CI: -19.82, 10.63; p = 0.561) and non-significantly lower ED-LOS (232 (IQR: 150 - 346) versus 296 (IQR: 212 - 330) minutes, absolute difference: -59 (-130.81, 12.81); p = 0.106).

Conclusion

The dexamethasone administration by EMS in pre-hospital setting for management of asthma and COPD patients is beneficial in reducing the ED-LOS and need for hospital admission but its effects are not statistically significant, except regarding the ED-LOS of asthma exacerbation cases.

Reducing oral steroid intolerability and drug costs for acute wheezers: A retrospective evaluation of a clinical management algorithm in a Pediatric Emergency Department

PROJECT AIM

To retrospectively evaluate a clinical management algorithm for acute wheezers in a UK Pediatric Emergency Department (PED).

OVERVIEW AND RATIONALE

Acute wheezing attacks are a leading cause of PED attendances and inpatient admissions. Prednisolone, a routine treatment, is intolerable in almost one-third of children, requiring repeated dosing, which may prolong length of stay (LOS). To address this problem, we: (1) developed an acute management algorithm (concise, single-sided flow-chart, instructing immediate management); (2) modified the OCS regime from prednisolone (1 mg/kg, 3-day course) to dexamethasone (600 then 300 mcg/kg); (3) and disseminated guidance regionally. Written information-handouts, e-mails, and posters-were followed-up with verbal reinforcement. We implemented the algorithm in 2017 and revised it further in 2018.

EVALUATION

In 2019, we retrospectively collected data on 100 acute wheeze attendances (those requiring OCS, aged 2-14), between October and December in 2016, 2017, and 2018 (n = 300), and assessed outcomes.

RESULTS

Over a 48-month period, we reduced OCS intolerability by 67.2% and OCS drug costs by 85.8% (saving £41,470.14), while not significantly influencing the other outcomes.

CONCLUSIONS

Reduced intolerability and substantial cost savings can be achieved by implementing a structured acute pediatric wheeze algorithm and modifying the OCS to single-dose dexamethasone (300 mcg/kg).

Trends and Variation in Pediatric Anaphylaxis Care From 2016 to 2022

BACKGROUND

Variation in the use of treatments and hospitalization for anaphylaxis would suggest a lack of consensus in therapeutic approach.

OBJECTIVE

To evaluate trends and practice variation in the emergency department (ED) care of children with anaphylaxis in a large US cohort.

METHODS

We conducted a 48-site retrospective cohort study using the Pediatric Health Information System from January 2016 through September 2022. Children younger than 18 years with a primary diagnosis of anaphylaxis were included. Care trends were assessed using negative binomial regression modeling. Rates of medication use, hospitalizations, and revisits were reported as medians with interquartile ranges (IQRs).

RESULTS

There were 42,909 ED visits for anaphylaxis, with a 4.2% per-year increase in visit incidence (95% CI, 1.8-6.7) during the study period. The median hospitalization rate was 3.5% (IQR, 2.2-6.0), and the 3-day ED revisit rate was 0.6% (IQR, 0.4-0.9). The hospital-level median use of therapies included intramuscular epinephrine (55.3%; IQR, 50.1-59.9), systemic steroids (73.8%; IQR, 63.9-81.4), antihistamines (59.9%; IQR, 53.5-65.5), H2-receptor antagonists (56.8%; IQR, 42.3-66.2), bronchodilators (15.1%; IQR, 12.5-17.0), inhaled epinephrine (1.1%; IQR, 0.6-1.9), and fluid boluses (19.8%; IQR, 11.3-29.3). Severe reactions requiring intensive care unit admission (1.5%; IQR, 0.8-2.2), vasopressors (0.3%; IQR, 0.0-0.6), and intubation (0.2%; IQR, 0.0-0.3) were rare.

CONCLUSIONS

ED visits for anaphylaxis increased during the study period, but hospitalization rates were low. Substantial variation exists between EDs regarding the use of anaphylaxis therapies, supporting the need for future research to evaluate the efficacy of these medications.

Dexamethasone versus methylprednisolone for critical asthma: A single center, open-label, parallel-group clinical trial

BACKGROUND

Evidence for the use of dexamethasone for pediatric critical asthma is limited. We sought to compare the clinical efficacy and safety of dexamethasone versus methylprednisolone among children hospitalized in the pediatric intensive care unit (PICU) for critical asthma.

METHODS

A prospective, single center, open-label, two-arm, parallel-group, nonrandomized trial among children ages 5-17 years hospitalized within the PICU from April 2019 to December 2021 for critical asthma consented to receive methylprednisolone (standard care) or dexamethasone (intervention) at a 2:1 allocation ratio, respectively. The intervention arm received intravenous dexamethasone 0.25 mg/kg/dose (max: 15 mg/dose) every 6 h for 48 h and the standard care arm intravenous methylprednisolone 1 mg/kg/dose every 6 h (max dose: 60 mg/dose) for 5 days. Study endpoints were clinical efficacy (i.e., length of stay [LOS], continuous albuterol duration, and a composite of adjunctive asthma interventions) and safety (i.e., corticosteroid-related adverse events).

RESULTS

Ninety-two participants were analyzed of whom 31 were allocated to the intervention arm and 61 the standard care arm. No differences in demographics, clinical characteristics, or acute/chronic asthma severity indices were observed. Regarding efficacy and safety endpoints, no differences in hospital LOS, continuous albuterol duration, adjunctive asthma intervention rates, or corticosteroid-related adverse events were noted. Compared to the intervention arm, participants in the standard care arm more frequently were prescribed corticosteroids at discharge (72% vs. 13%, p < 0.001).

CONCLUSIONS

Among children hospitalized for critical asthma, dexamethasone appears safe and warrants further investigation to fully assess clinical efficacy and potential advantages over commonly applied agents such as methylprednisolone.

Spatial metabolomics reveal mechanisms of dexamethasone against pediatric pneumonia

Currently, drugs are limited to treating pediatric pneumonia in clinical practice. It is urgent to find one new precise prevention and control therapy. The dynamically changing biomarkers during the development of pediatric pneumonia could help diagnose this disease, determine its severity, assess the risk of future events, and guide its treatment. Dexamethasone has been recognized as an effective agent with anti-inflammatory activity. However, its mechanisms against pediatric pneumonia remain unclear. In this study, spatial metabolomics was used to reveal the potential and characteristics of dexamethasone. Specifically, bioinformatics was first applied to find the critical biomarkers of differential expression in pediatric pneumonia. Subsequently, Desorption Electrospray Ionization mass spectrometry imaging-based metabolomics screened the differential metabolites affected by dexamethasone. Then, a gene-metabolite interaction network was built to mark functional correlation pathways for exploring integrated information and core biomarkers related to the pathogenesis and etiology of pediatric pneumonia. Further, these were validated by molecular biology and targeted metabolomics. As a result, genes of Cluster of Differentiation19, Fc fragment of IgG receptor IIb, Cluster of Differentiation 22, B-cell linker, Cluster of Differentiation 79B and metabolites of Triethanolamine, Lysophosphatidylcholine(18:1(9Z)), Phosphatidylcholine(16:0/16:0), phosphatidylethanolamine(O-18:1(1Z)/20:4(5Z,8Z,11Z,14Z)) were identified as the critical biomarkers in pediatric pneumonia. B cell receptor signaling pathway and glycerophospholipid metabolism were integrally analyzed as the main pathways of these biomarkers. The above data were illustrated using a Lipopolysaccharides-induced lung injury juvenile rat model. This work will provide evidence for the precise treatment of pediatric pneumonia.

Study on the Mechanism of Qing-Fei-Shen-Shi Decoction on Asthma Based on Integrated 16S rRNA Sequencing and Untargeted Metabolomics

Qing-Fei-Shen-Shi decoction (QFSS) consists of Prunus armeniaca L., Gypsum Fibrosum, Smilax glabra Roxb., Coix lacryma-jobi L., Benincasa hispida (Thunb.) Cogn., Plantago asiatica L., Pyrrosia lingua (Thunb.) Farw., Houttuynia cordata Thunb., Fritillaria thunbergii Miq., Cicadae Periostracum, and Glycyrrhizae Radix Et Rhizoma Praeparata Cum Melle. QFSS shows significant clinical efficacy in the treatment of asthma. However, the specific mechanism of QFSS on asthma remains unclear. Recently, multiomics techniques are widely used in elucidating the mechanisms of Chinese herbal formulas. The use of multiomics techniques can better illuminate the multicomponents and multitargets of Chinese herbal formulas. In this study, ovalbumin (OVA) was first employed to induce an asthmatic mouse model, followed by a gavage of QFSS. First, we evaluated the therapeutic effects of QFSS on the asthmatic model mice. Second, we investigated the mechanism of QFSS in treating asthma by using an integrated 16S rRNA sequencing technology and untargeted metabolomics. Our results showed that QFSS treatment ameliorated asthma in mice. In addition, QFSS treatment affected the relative abundances of gut microbiota including Lactobacillus, Dubosiella, Lachnospiraceae_NK4A136_group, and Helicobacter. Untargeted metabolomics results showed that QFSS treatment regulated the metabolites such as 2-(acetylamino)-3-[4-(acetylamino) phenyl] acrylic acid, D-raffinose, LysoPC (15 : 1), methyl 10-undecenoate, PE (18 : 1/20 : 4), and D-glucose6-phosphate. These metabolites are associated with arginine and proline metabolism, arginine biosynthesis, pyrimidine metabolism, and glycerophospholipid metabolism. Correlation analysis indicated that arginine and proline metabolism and pyrimidine metabolism metabolic pathways were identified as the common metabolic pathways of 16s rRNA sequencing and untargeted metabolomics. In conclusion, our results showed that QFSS could ameliorate asthma in mice. The possible mechanism of QFSS on asthma may be associated with regulating the gut microbiota and arginine and proline metabolism and pyrimidine metabolism. Our study may be useful for researchers to study the integrative mechanisms of Chinese herbal formulas based on modulating gut microbiota and metabolism.

Dexamethasone versus prednisone/prednisolone in the management of pediatric patients with acute asthmatic exacerbations: a systematic review and meta-analysis

OBJECTIVE

Acute asthmatic exacerbation is a common condition for pediatric emergency visits. Recently, dexamethasone has increasingly been used as an alternative to prednisone. This study aimed to evaluate the safety and efficacy of dexamethasone (DEX) against prednisone/prednisolone (PRED) in managing pediatric patients with acute asthmatic exacerbation.

DATA SOURCES

Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to August 2022 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42022353462).

STUDY SELECTIONS

From 316 studies screened, seventeen studies met the eligibility criteria, with 5967 pediatric patients experiencing an asthma exacerbation requiring treatment with either DEX (n = 2865) or PRED (n = 3102). Baseline patient characteristics (age, sex, PRAM (pediatric respiratory assessment measure), previous corticosteroid and beta-agonist inhaler) were comparable between groups.

RESULTS

After treatment administration, the DEX group had fewer vomiting incidents (OR = 0.24, 95% CI: 0.11, 0.51, I² = 58%) and reduced noncompliance events (OR = 0.12, 95% CI: 0.04, 0.34, I² = 0%) when compared to the PRED group. Regarding emergency-department (ED)-related outcomes, there were no differences in hospital admission rates (OR = 0.83, 95% CI: 0.58, 1.19, I² = 15%), time spent in the ED (MD= -0.11 h, 95% CI: -0.52; 0.30, I² = 82%) or relapse occurrences (OR = 0.67, 95% CI: 0.30, 1.49, I² = 52%) between both groups.

CONCLUSION

Although there were no differences between the DEX and PRED groups in terms of hospital admission rates, time spent in the ED or relapse events, pediatric patients receiving DEX experienced lower noncompliance and vomiting rates.

Carbocistein improves airway remodeling in asthmatic mice

BACKGROUND

The alleviating effects of carbocisteine (S-carboxymethylcysteine, SCMC) have been implicated in chronic obstructive pulmonary disease; however, very little is known about its mechanisms in asthma. In this study, we aimed to investigate the effects of SCMC on airway remodeling in asthmatic mice induced by ovalbumin (OVA).

METHODS

The asthma mouse model was generated by OVA sensitization and stimulation and subsequently intervened by SCMC or dexamethasone. Bronchoalveolar lavage fluid (BALF) and lung tissues were collected from each group of mice. The TGF-β1 levels in BALF were measured by ELISA. Masson's staining was used to detect collagen fiber deposition in mouse airway tissues, while immunohistochemistry and RT-qPCR were conducted to examine the protein and mRNA expression of TGF-β1 in mouse lung airway tissues, respectively. The correlation between TGF-β1 mRNA expression and the area of collagen fiber deposition in airway tissues was analyzed by Pearson's correlation coefficient.

RESULTS

The area of collagen fiber deposition in the airway tissues of asthmatic mice was significantly increased, while SCMC alleviated the collagen fiber deposition in the airway tissues. TGF-β1 expression was significantly elevated in BALF and airway tissues of asthmatic mice, while SCMC inhibited TGF-β1 expression. TGF-β1 expression was significantly and positively correlated with collagen fiber deposition in mouse airway tissues.

CONCLUSIONS

SCMC intervention improves collagen fiber deposition in airway tissues and inhibits TGF-β1 expression in asthmatic mice.

Hospital's observed specific standard practice: A novel measure of variation in care for common inpatient pediatric conditions

BACKGROUND

Previously few means existed to broadly examine variability across conditions/practices within or between hospitals for common pediatric conditions.

OBJECTIVE

Our objective was to develop a novel empiric measure of variation in care and test its association with patient-centered outcomes.

DESIGNS

We conducted a retrospective cohort study of children hospitalized from January 2016 to December 2018 using the Pediatric Hospital Information Systems database.

SETTINGS AND PARTICIPANTS

We included children ages 0-18 years hospitalized with asthma, bronchiolitis, or gastroenteritis.

INTERVENTION

We developed a hospital-specific measure of variation in care, the hospital's observed specific standard practice (HOSSP), the most common combination of laboratory studies, imaging, and medications used at each hospital.

MAIN OUTCOME AND MEASURES

The outcomes were standardized costs, length of stay (LOS), and 7-day all-cause readmissions.

RESULTS

Among 133,392 hospitalizations from 41 hospitals (asthma = 50,382, bronchiolitis = 54,745, and gastroenteritis = 28,265), there was significant variation in overall HOSSP adherence across hospitals for these conditions (asthma: 3.5%-47.4% [p < .001], bronchiolitis: 2.5%-19.8% [p < .001], gastroenteritis: 1.6%-11.6% [p < .001]). The majority of HOSSP variation was driven by differences in medication prescribing for asthma and bronchiolitis and laboratory ordering for gastroenteritis. For all three conditions, greater HOSSP adherence was associated with significantly lower hospital costs (asthma: p = .04, bronchiolitis: p < .001, acute gastroenteritis: p = .01), without increases in LOS or 7-day all cause readmissions.

CONCLUSION

We found substantial variation in the components and adherence to HOSSP. Hospitals with greater HOSSP adherence had lower costs for these conditions. This suggests hospitals can use data around laboratory, imaging, and medication prescribing practices to drive standardization of care, reduce unnecessary testing and treatment, determine best practices, and reduce costs.

Single-Dose Dexamethasone Is Not Inferior to 2 Doses in Mild to Moderate Pediatric Asthma Exacerbations in the Emergency Department

OBJECTIVE

The purpose of this study was to compare the efficacy of a single dose of dexamethasone to 2 doses of dexamethasone in treating mild to moderate asthma exacerbations in pediatric patients. We anticipated that there would not be a difference in the rate of return visits to the emergency department (ED), urgent care, or primary care physician for continued asthma symptoms.

METHODS

This was a prospective, randomized, single-center, unblinded, parallel-group randomized clinical trial of patients 2 to 20 years old presenting to a pediatric ED with mild to moderate asthma exacerbations. The patients were randomized to receive 1 or 2 doses of dexamethasone (0.6 mg/kg per dose, maximum of 16 mg). Telephone follow-up interviews were performed on the sixth day after ED visit. The primary outcome measures were return visits to either primary care physician or ED for continued asthma symptoms. Secondary outcomes were days of symptoms, missed school days, and adverse effects.

RESULTS

Of the 318 children initially enrolled, 308 patients met the enrollment criteria. These patients were randomized into 2 groups. There were 116 patients in group 1 and 116 patients in group 2. There was no significant difference between groups regarding return visits (group 1, 12.1%; group 2, 10.3%; odds ratio [OR], 0.892 [95% confidence interval {CI}, 0.377-2.110]), days to symptom resolution (group 1, 2.4; group 2, 2.5; OR, 0.974 [95% 95% CI, 0.838-1.132]), missed school days (group 1, 47%; group 2, 51%; OR, 1.114 [95% CI, 0.613-2.023]), or vomiting (group 1, 8.6%; group 2, 3.4%; OR, 2.424 [95% CI, 0.637-9.228]).

CONCLUSIONS

In this single-center, unblinded randomized trial of children and adolescents with mild to moderate acute exacerbations of asthma, there was no difference in the rate of return visits for continued or worsened symptoms between patients randomized to 1 or 2 doses of dexamethasone.

A Randomized Controlled Study Addressing Dexamethasone Tolerability in the Treatment of Acute Asthma in Children: Mary Poppins on Trial!

AIM

Emesis of oral medications continues to be a problem in the management of acute pediatric asthma exacerbations; therefore, we set out to assess whether smaller volumes of oral dexamethasone resulted in better tolerability.

METHODS

Children aged 2-14 years, presenting to the emergency department with acute asthma exacerbation, were enrolled in this open, prospective randomized controlled trial. Participants received 0.3 mg/kg of dexamethasone in either its concentrated volume (10 mg/mL) or mixed with Ora Sweet (1 mg/mL). Tolerability was measured by vomiting within 45 minutes of receiving dexamethasone, with stratification, a priori, for prior vomiting.

RESULTS

430 participants were enrolled. 23/213 (11%) in the 10 mg/mL group vomited dexamethasone compared to 16/217 (7%) in the 1 mg/mL group (P = .29). 11/179 (6%) in the 10 mg/mL group vomited compared to 8/183 (3%) in the 1 mg/mL group (.61). For those 68 stratified with prior vomiting, 12/34 (35%) in the 10 mg/mL group vomited compared to 8/34 (24%) in the 1 mg/mL group (P = .43). None of these results were statistically different. Prior vomiting increased the risk of vomiting, regardless of the formulation given (P < .001).

CONCLUSIONS

Volume does not play a significant role in the tolerability of dexamethasone. Therefore, palatability should not be sacrificed for a smaller volume of dexamethasone to improve tolerability.

Dexamethasone for Pediatric Critical Asthma: A Multicenter Descriptive Study

BACKGROUND

Systemic corticosteroids are vital to critical asthma management. While intravenous methylprednisolone is routinely used in the pediatric intensive care unit (PICU) setting, recent data supports dexamethasone as an alternative. Using the Pediatric Health Information System (PHIS) registry, we assessed trends and variation in corticosteroid prescribing among children hospitalized for critical asthma.

METHODS

We performed a multicenter retrospective cohort study using PHIS data among children 3-17 years of age admitted for critical asthma from 2011 through 2019. Primary outcomes were corticosteroid prescribing rates by year and participating sites. Exploratory outcomes were corticosteroid-related adverse effects, rates of adjunctive pharmaceutical and respiratory interventions, mortality and length of stay.

RESULTS

Of the 49 children's hospitals assessed, 26 907 encounters were included for study. Mean dexamethasone exposure rates were 18.1 ± 2.4% where 2.4 ± 1.2% represented dexamethasone-alone prescribing. Dexamethasone alone prescribing exhibited a linear trend (annual increase of 0.5 ± 0.1% annually R² = 0.845) without correlation to cumulative site critical asthma admission rates. Compared to encounters prescribed solely methylprednisolone or a combination of dexamethasone and methylprednisolone, subjects provided dexamethasone alone had reduced asthma severity indices, length of stay, and exposure rates to adjunctive asthma interventions. Adverse events were rare and the dexamethasone-alone group less frequently experienced gastritis and hyperglycemia.

CONCLUSIONS

In this multicenter retrospective study from 49 children's hospitals, dexamethasone prescribing rates appear increasing for pediatric critical asthma. Observed variability in corticosteroid prescribing implies a continued need for controlled prospective comparative analyses to define ideal corticosteroid regimens for pediatric critical asthma.

Dexamethasone Versus Prednisone in Children Hospitalized With Asthma Exacerbation

OBJECTIVES

Dexamethasone is increasingly used for the management of children hospitalized with asthma in place of prednisone, yet data regarding the effectiveness of dexamethasone in children with asthma exacerbation severe enough to require hospitalization are limited. Our objective is to compare the effectiveness of dexamethasone versus prednisone in children hospitalized with an asthma exacerbation on 30-day reutilization.

METHODS

We conducted a retrospective cohort study at an urban, quaternary children's hospital of children aged 4 to 17 years, hospitalized from January 1, 2014 to December 31, 2017, with a primary discharge diagnosis of asthma. A covariate-balanced propensity score was derived to account for physician discretion in steroid selection. A generalized linear model, including inverse probability treatment weighting, was used to detect differences in 30-day return utilization (unplanned readmission or emergency department visit) between children whose first dose of corticosteroid was dexamethasone versus prednisone.

RESULTS

Inclusion criteria were met by 1161 patients, of which 510 (44%) first received dexamethasone versus 651 (56%) who first received prednisone. The total cohort had a mean age of 8.5 years (SD 3.4). The covariate-balanced cohort had no significant differences in demographic characteristics or illness severity between groups. The dexamethasone group had a return utilization of 3.9% (20 of 510) versus 2.2% (14 of 651) for children treated with prednisone. The propensity score-adjusted analysis revealed the steroid treatment was not found to significantly affect the 30-day reutilization (adjusted odds ratio [aOR] 1.61; 95%CI 0.80-3.31).

CONCLUSIONS

The initial steroid choice (dexamethasone versus prednisone) was not associated with 30-day reutilization after hospitalization for an asthma exacerbation.

Comparative effectiveness of oral dexamethasone vs. oral prednisolone for acute exacerbation of asthma: A randomized control trial

Background:

Acute exacerbation of asthma is a common condition leading to emergency visits. Prednisolone is a commonly prescribed drug in the standard management of acute exacerbation of asthma along with other drugs. This study was planned to see the efficacy of oral dexamethasone when compared with oral prednisolone in the management of acute exacerbation of asthma.

Methods:

A single-center pilot study in the form of randomized control trial was done by recruiting children aged 2–14 years diagnosed with acute asthma exacerbation with mild to moderate severity. A total of 88 patients received oral dexamethasone (0.3 mg/kg) in two doses 24 h apart, which was compared with 87 patients who received oral prednisolone (1 mg/kg) in two divided doses 12 h apart for 5 days. The patients were assessed at the time of admission (zero hour), at 4^th hour, and on the 5^th day by various parameters such as respiratory rate, use of accessory muscles, Pediatric Respiratory Assessment Measure (PRAM) score, peak expiratory flow rate (PEFR), 6-h admission stay, and rate of hospital admission.

Results:

Baseline demographic profile, clinical characteristics, comorbidities, indoor pollution, and use of Metered Dose Inhaler (MDI) among the two study groups were comparable. Six-hour emergency stay and rate of admission were significantly lower in the dexamethasone group (P < 0.05). Improvement in PRAM score, PEFR, use of accessory muscles, and respiratory rate was also better in dexamethasone group at the 4^th hour and 5^th day (P < 0.05). In addition, oral dexamethasone was shown to have less incidence of vomiting/gastritis than prednisolone (P < 0.05).

Conclusion:

Oral dexamethasone can be considered a reliable and better option as compared with prednisolone due to its faster action and minimal side effects.

Dexamethasone Versus Prednisone in Children Hospitalized for Acute Asthma Exacerbations

BACKGROUND AND OBJECTIVES

Extensive literature supports using dexamethasone (DEX) in children presenting to the emergency department (ED) with mild-to-moderate asthma exacerbations; however, only limited studies have assessed this in hospitalized children. In this study, we evaluate the outcomes of DEX versus prednisone/prednisolone (PRED) use in children hospitalized for mild-to-moderate asthma exacerbations.

METHODS

This multisite retrospective cohort study included children between 3 and 21 years of age hospitalized to a tertiary care children's hospital system between January 1, 2013, and December 31, 2017, with a primary discharge diagnosis of acute asthma exacerbation or status asthmaticus. Primary study outcome was mean hospital length of stay (LOS). Secondary outcomes included PICU transfers during initial hospitalization and ED revisits and hospital readmissions within 10 days after discharge. Generalized linear models were used to model logged LOS as a function of steroid and demographic and clinical covariates. The analysis was stratified by initial steroid timing.

RESULTS

Of the 1410 children included, 981 received only DEX and 429 received only PRED. For children who started oral steroids after hospital arrival, DEX cohort had a significantly shorter adjusted mean hospital LOS (DEX 24.43 hours versus PRED 29.38 hours; P = .03). For children who started oral steroids before hospital arrival, LOS did not significantly differ (DEX 26.72 hours versus PRED 25.20 hours; P = .45). Rates of PICU transfers, ED revisits, and hospital readmissions were uncommon events.

CONCLUSION

Children hospitalized with mild-to-moderate asthma exacerbations have significantly shorter hospital LOS when starting DEX rather than PRED on admission.

Pharmacogenomic considerations for repurposing of dexamethasone as a potential drug against SARS-CoV-2 infection

Immunomodulatory and analgesic effects of dexamethasone are clinically well established, and this synthetic corticosteroid acts as an agonist of glucocorticoid receptors. Early results of the RECOVERY Trial from the United Kingdom and others suggest certain benefits of dexamethasone against COVID-19 chronic patients. The efforts have been acknowledged by World Health Organization with an interim guideline to use in patients with a severe and critical illness. The inherent genetic variations in genes such as CYP3A5, NR3C1, NR3C2, etc., involved in the pharmacokinetic and pharmacodynamic processes may influence dexamethasone's effects as an anti-inflammatory drug. Besides, the drug may influence transcriptome or metabolic changes in the individuals. In the present review, we summarize the reported genetic variations that impact dexamethasone response and discuss dexamethasone-induced changes in transcriptome and metabolome that may influence potential treatment outcome against COVID-19.

Dexamethasone Versus Prednisone for Pediatric Acute Asthma Exacerbations: Specialists' Practice Patterns

BACKGROUND AND OBJECTIVE

Dexamethasone has emerged as a viable alternative to prednisone in the treatment of pediatric acute asthma exacerbations, with the potential for improved compliance secondary to decreased frequency of dosing, improved taste, and decreased cost. The objective of this study is to identify whether providers are prescribing dexamethasone for pediatric acute asthma exacerbations. Secondary objectives are to describe variation in practice between different specialties and to identify the commonly used dosing and frequency for dexamethasone.

METHODS

We conducted a cross-sectional, descriptive study with an anonymous, web-based survey (surveymonkey.com). The survey population included all fellowship program directors listed on FRIEDA Online for pediatric emergency medicine, pediatric pulmonology, and allergy and immunology, and emergency medicine residency directors through the Council of Emergency Medicine Residency Directors listserv. Program directors were contacted via e-mail up to 5 times for 3 months.

RESULTS

Overall, 300 respondents (70% of the program directors) completed the survey. Response rates by specialty varied from 60% to 94%. One third of providers are using dexamethasone, whereas just more than half of providers (51%) are prescribing a 5-day prednisone course. The preferred maximum dose for dexamethasone is 10 mg (45%), with 82% using a dose of 0.6 mg/kg.Pediatric emergency medicine fellowship directors demonstrated a preference for dexamethasone (59%). Prednisone is favored by emergency medicine (56%), pediatric pulmonology (89%), and allergy and immunology (93%) program directors.

CONCLUSIONS

Although most pediatric emergency medicine academic physicians have transitioned to using dexamethasone to treat acute pediatric asthma exacerbations, other specialties continue to favor prednisone.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

Cannabidiol-Driven Alterations to Inflammatory Protein Landscape of Lipopolysaccharide-Activated Macrophages In Vitro May Be Mediated by Autophagy and Oxidative Stress

Background: The nonpsychotropic phytocannabinoid cannabidiol (CBD) presents itself as a potentially safe and effective anti-inflammatory treatment relative to clinical standards. In this present study, we compare the capacity of CBD to the corticosteroid dexamethasone (Dex) in altering the secreted protein landscape of activated macrophages and speculate upon the mechanism underpinning these alterations. Materials and Methods: Human THP-1 monocytes were differentiated into macrophages (THP-1 derived macrophages [tMACs]), activated with lipopolysaccharide (LPS), and then treated with 5, 10, 25, 50, or 100 μM CBD or 10 μM Dex for 24 h. Following treatment, cytotoxicity of CBD and protein expression levels from culture supernatants and from whole cell lysates were assessed for secreted and intracellular proteins, respectively. Results: High concentration (50 and 100 μM) CBD treatments exhibit a cytotoxic effect on LPS-activated tMACs following the 24-h treatment. Relative to the LPS-activated and untreated control (M[LPS]), both 25 μM CBD and 10 μM Dex reduced expression of pro-inflammatory markers-tumor necrosis factor alpha, interleukin 1 beta, and regulated on activation, normal T cell expressed and secreted (RANTES)-as well as the pleiotropic marker interleukin-6 (IL-6). A similar trend was observed for anti-inflammatory markers interleukin-10 and vascular endothelial growth factor (VEGF). Dex further reduced secreted levels of monocyte chemoattractant protein-1 in addition to suppressing IL-6 and VEGF beyond treatments with CBD. The anti-inflammatory capacity of 25 μM CBD was concurrent with reduction in levels of phosphorylated mammalian target of rapamycin Ser 2448, endothelial nitric oxide synthase, and induction of cyclooxygenase 2 relative to M(LPS). This could suggest that the observed effects on macrophage immune profile may be conferred through inhibition of mammalian target of rapamycin complex 1 and ensuing induction of autophagy. Conclusion: Cumulatively, these data demonstrate cytotoxicity of high concentration CBD treatment. The data reported herein largely agree with other literature demonstrating the anti-inflammatory effects of CBD. However, there is discrepancy within literature surrounding efficacious concentrations and effects of CBD on specific secreted proteins. These data expand upon previous work investigating the effects of CBD on inflammatory protein expression in macrophages, as well as provide insight into the mechanism by which these effects are conferred.

Paediatrics: how to manage acute asthma exacerbations

Background

Asthma is the most common chronic disease of childhood and a major source of childhood health burden worldwide. These burdens are particularly marked when children experience characteristic ‘symptom flare-ups’ or acute asthma exacerbations (AAEs). AAE are associated with significant health and economic impacts, including acute Emergency Department visits, occasional hospitalizations, and rarely, death. To treat children with AAE, several medications have been studied and used.

Methods

We conducted a narrative review of the literature with the primary objective of understanding the evidence of their efficacy. We present this efficacy evidence in the context of a general stepwise management pathway for paediatric AAEs. This framework is developed from the combined recommendations of eight established (inter)national paediatric guidelines.

Discussion

Management of paediatric AAE centres around four major care goals: (1) immediate and objective assessment of AAE severity; (2) prompt and effective medical interventions to decrease respiratory distress and improve oxygenation; (3) appropriate disposition of patient; and (4) safe discharge plans. Several medications are currently recommended with varying efficacies, including heliox, systemic corticosteroids, first-line bronchodilators (salbutamol/albuterol), adjunctive bronchodilators (ipratropium bromide, magnesium sulfate) and second-line bronchodilators (aminophylline, i.v. salbutamol, i.v. terbutaline, epinephrine, ketamine). Care of children with AAE is further enhanced using clinical severity scoring, pathway-driven care and after-event discharge planning.

Conclusions

AAEs in children are primarily managed by medications supported by a growing body of literature. Continued efforts to study the efficacy of second-line bronchodilators, integrate AAE management with long-term asthma control and provide fair/equitable care are required.

Inpatient management of an acute asthma exacerbation using clinical care pathways

Asthma exacerbations remain a leading cause of hospitalization in the pediatric population, and many children who require hospitalization for status asthmaticus are managed using clinical care pathways (CPGs). Clinical care pathways are often created or adopted by healthcare systems in order to establish specific, evidence-based guidelines that standardize and coordinate quality care in both the emergency room and inpatient settings. This paper reviews the use of these guidelines and the updated evidence-based recommendations regarding best-practice for acute asthma care of hospitalized children, including the 2020 recommendations from the National Asthma Education and Prevention Program Expert Panel (NAEPP).

Betamethasone versus dexamethasone for inpatient preschool wheezing-A case-control study

BACKGROUND AND OBJECTIVES

Wheezing is one of the most common reasons for the presentation of children to primary care or the emergency ward, before 7 years of age. Current guidelines recommend a short course of oral corticosteroids (OCS) for those children with a wheezing attack severe enough to require hospitalization. However, the optimal choice of therapy is controversial. We aimed to compare the efficacy of betamethasone to that of dexamethasone in achieving clinical response in preschool children requiring hospitalization for an acute wheezing attack.

METHODS

This was a retrospective study. Medical records of healthy children without significant comorbidities between 1 and 7 years of age (n = 234) admitted with a moderate-severity acute wheezing attack to two pediatric wards between 2014 and 2018 were included. All children were treated with either betamethasone or dexamethasone exclusively during the hospitalization. The primary outcome of interest was the length of hospital stay (LOS).

RESULTS

The demographic parameters and the clinical severity of wheezing episodes were similar in the two study groups, as was the LOS. However, the dexamethasone cumulative dose used during hospitalization was significantly larger than the betamethasone cumulative dose (3.76 (1.88-5.64) vs. 1.86 (1.24-3.1) mg/kg of prednisone-equivalent dose, p < .001).

CONCLUSION

In preschool children with acute wheezing requiring hospitalization, betamethasone achieved a similar clinical response when compared to dexamethasone, with a lower cumulative steroid dose. Further studies are needed to understand the additional benefits of betamethasone over other steroids or placebo.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Systemic glucocorticoid at discharge after hospitalization for pediatric asthma: a prospective pilot study

OBJECTIVE: 

We examined asthma control in children hospitalized for status asthmaticus 7-10 days after discharge with or without an additional prescription for systemic corticosteroids.

METHODS: 

This was a prospective observational study of patients aged 5-17 years with a documented history of asthma or β-agonist responsive wheezing admitted to the hospital for an acute asthma exacerbation. We compared patients who had any systemic corticosteroid prescribed at discharge with those who were not prescribed systemic corticosteroids at discharge. The primary outcomes were asthma control after discharge, as defined by the Asthma Control Test (ACT), and missed school days, which we modeled with multivariable linear and Poisson regression, respectively.

RESULTS: 

A total of 56 patients were included in the study, 29 (52%) received dexamethasone inpatient and then were discharged without additional prescribed systemic corticosteroids. Those without a corticosteroid prescription at discharge were less likely to have received noninvasive ventilation (p = 0.02), pulmonology consultation (p = 0.02), and continuous albuterol (p = 0.01) during hospitalization. These patients also tended toward shorter length of stay (p = 0.07) compared to those receiving systemic corticosteroid prescription at discharge. In multivariable models, being discharged without systemic corticosteroid prescription was associated with poorer asthma control after discharge [beta (95% CI), -2.21 (-2.65 to -1.77)] and more missed school days [coefficient estimate (95% CI), 0.87 (0.07-1.68)].

CONCLUSIONS

After hospitalization for an asthma exacerbation, patients not given systemic corticosteroids at discharge tended to have worse asthma control following discharge despite having less severe disease and requiring less aggressive inpatient management.

Supplemental data for this article can be accessed at publisher's website.

Methylprednisolone, dexamethasone or hydrocortisone for acute severe pediatric asthma: does it matter?

OBJECTIVE

Various intravenous (IV) corticosteroids are available for acute severe asthma (ASA) treatment. The choice of IV corticosteroids varies broadly and depends on institution, country, or physician preferences. In this study, we compared the efficacy of IV methylprednisolone, hydrocortisone and dexamethasone in ASA treatment during pediatric intensive care unit (PICU) admission.

METHODS

The study was a prospective randomized clinical trial. We enrolled patients of 1-21 years after they were admitted to the PICU requiring continuous beta-2 agonist treatment. Patients were randomized into three groups: Group A: IV Methylprednisolone, Group B: IV Hydrocortisone and Group C: IV Dexamethasone. The primary outcomes measured were durations of beta-2 agonist continuous nebulization treatment. Secondary outcomes, included PICU and hospital length of stay (LOS), pediatric asthma severity score (PASS), need for mechanical ventilation and maximum dose of beta-2 agonist treatment.

RESULTS

61 patients were included in the analysis. 22 patients recruited in Group A, 20 in group B and 19 group C. Median durations of beta-2-agonist treatment were 23 h (QR 16-38) for methylprednisolone, 27 h (QR 16-40) for hydrocortisone, and 32 h (QR 16-48) for dexamethasone (p = 0.90). There was no difference in PICU LOS, hospital LOS, PASS score, B2 agonist maximum dose, or need for ventilation support.

CONCLUSIONS

The use of IV methylprednisolone, hydrocortisone, and dexamethasone have equivalent efficacy when used at the appropriate doses. Studies with larger cohorts are needed to compare the effectiveness of IV corticosteroids in the management of ASA in the PICU setting.

Emergency department treatment of asthma in children: A review

Asthma is the most common chronic illness in children, with >700,000 emergency department (ED) visits each year. Asthma is a respiratory disease characterized by a combination of airway inflammation, bronchoconstriction, bronchial hyperresponsiveness, and variable outflow obstruction, with clinical presentations ranging from mild to life-threatening. Standardized ED treatment can improve patient outcomes, including fewer hospital admissions. Informed by the most recent guidelines, this review focuses on the optimal approach to diagnosis and treatment of children with acute asthma exacerbations who present to the ED.

Comparison of Learning Effects of Virtual Reality Simulation on Nursing Students Caring for Children with Asthma

With the global pandemic of the coronavirus disease, virtual reality simulation (vSim) has emerged as a simulation educational method. The purpose of this study is to examine the learning effects of vSim by comparing three different educational modalities of nursing care for children with asthma. A quasi-experimental design with three different teaching methods, vSim, high-fidelity simulation (HFS), and vSim with HFS, were used in the study. The group using vSim with HFS showed the highest scores in knowledge, confidence in practice, and performance compared to groups using vSim or HFS alone. Simulation practice using vSim combined with HFS could be an effective educational method for nursing students.

Pediatric respiratory distress: California out-of-hospital protocols and evidence-based recommendations

OBJECTIVES

Prehospital protocols vary across local emergency medical service (EMS) agencies in California. We sought to develop evidence-based recommendations for the out-of-hospital evaluation and treatment of pediatric respiratory distress, and we evaluated the protocols for pediatric respiratory distress used by the 33 California local EMS agencies.

METHODS

Evidence-based recommendations were developed through an extensive literature review of the current evidence regarding out-of-hospital treatment of pediatric patients with respiratory distress. The authors compared the pediatric respiratory distress protocols of each of the 33 California local EMS agencies with the evidence-based recommendations. Our focus was on the treatment of 3 main pediatric respiratory complaints by presentation: stridor (croup), wheezing < 24 months (bronchiolitis), and wheezing > 24 months (asthma).

RESULTS

Protocols across the 33 California local EMS agencies varied widely. Stridor (croup) had the highest protocol variability of the 3 presentations we evaluated, with no treatment having uniform use among all agencies. Only 3 (9.1%) of the local EMS agencies differentiated wheezing in children < 24 months of age, referencing this as possible bronchiolitis. All local EMS agencies included albuterol and epinephrine (intravenous/intramuscular) in their pediatric wheezing (asthma) treatment protocols. The least common treatments for wheezing (asthma) included nebulized epinephrine (3/33) and magnesium (2/33). No agencies included steroids in their treatment protocols (0/33).

CONCLUSION

Protocols for pediatric respiratory distress vary widely across the state of California, especially among those for stridor (croup) and wheezing in < 24 months (bronchiolitis). The evidence-based recommendations that we present for the prehospital treatment of these conditions may be useful for EMS medical directors tasked with creating and revising these protocols.

Intranasal Dexamethasone Reduces Mortality and Brain Damage in a Mouse Experimental Ischemic Stroke Model

Neuroinflammation triggered by the expression of damaged-associated molecular patterns released from dying cells plays a critical role in the pathogenesis of ischemic stroke. However, the benefits from the control of neuroinflammation in the clinical outcome have not been established. In this study, the effectiveness of intranasal, a highly efficient route to reach the central nervous system, and intraperitoneal dexamethasone administration in the treatment of neuroinflammation was evaluated in a 60-min middle cerebral artery occlusion (MCAO) model in C57BL/6 male mice. We performed a side-by-side comparison using intranasal versus intraperitoneal dexamethasone, a timecourse including immediate (0 h) or 4 or 12 h poststroke intranasal administration, as well as 4 intranasal doses of dexamethasone beginning 12 h after the MCAO versus a single dose at 12 h to identify the most effective conditions to treat neuroinflammation in MCAO mice. The best results were obtained 12 h after MCAO and when mice received a single dose of dexamethasone (0.25 mg/kg) intranasally. This treatment significantly reduced mortality, neurological deficits, infarct volume size, blood-brain barrier permeability in the somatosensory cortex, inflammatory cell infiltration, and glial activation. Our results demonstrate that a single low dose of intranasal dexamethasone has neuroprotective therapeutic effects in the MCAO model, showing a better clinical outcome than the intraperitoneal administration. Based on these results, we propose a new therapeutic approach for the treatment of the damage process that accompanies ischemic stroke.

Clinical factors associated with the use of dexamethasone for asthma in the pediatric emergency department

BACKGROUND

Dexamethasone is efficacious for the treatment of pediatric asthma exacerbations but is not specifically recommended by current national guidelines.

OBJECTIVES

To describe the factors associated with prescribed dexamethasone in a pediatric emergency department (PED) and upon patient discharge.

METHODS

Retrospective chart review of patients aged 2 to 18 years discharged home from a PED with a diagnostic code for asthma (J45x). Descriptive statistics are reported and binary logistic regression with generalized estimating equations was used to examine the demographic and clinical factors associated with dexamethasone use in the PED and upon discharge.

RESULTS

594 children contributed 690 visits for asthma. Two-thirds of patients received prednisone in the PED (n = 430; 62%). Among 260 children who received dexamethasone, 76% (n = 198) were prescribed a second dose for post-discharge administration. Multivariable models showed that patients triaged as most urgent had a 50% reduction in the odds of receiving dexamethasone in the PED (OR = 0.5; 95% CI = 0.28-0.87). Patients seen by a pediatrician (OR 4.2; 95%CI 2.1-8.3) and those triaged as urgent (OR 2.9; 95% CI = 1.8-7.8) were more likely to receive a single dose of dexamethasone.

CONCLUSIONS

Dexamethasone is less commonly used in the PED for asthmatic patients triaged as most urgent. Triage acuity and level of training were associated with single-dose treatment of asthma in those receiving dexamethasone. Further studies are needed to clarify the use of dexamethasone across the spectrum of asthma severity.

Anti-Inflammatory Effects of a Cordyceps sinensis Mycelium Culture Extract (Cs-4) on Rodent Models of Allergic Rhinitis and Asthma

Allergic rhinitis and asthma are common chronic allergic diseases of the respiratory tract, which are accompanied by immunoglobulin E (IgE)-mediated inflammation and the involvement of type 2 T helper cells, mast cells, and eosinophils. Cordyceps sinensis (Berk.) Sacc is a fungal parasite on the larva of Lepidoptera. It has been considered to be a health-promoting food and, also, one of the best-known herbal remedies for the treatment of airway diseases, such as asthma and lung inflammation. In the present study, we demonstrated the antiallergic rhinitis effect of Cs-4, a water extract prepared from the mycelium culture of Cordyceps sinensis (Berk) Sacc, on ovalbumin (OVA)-induced allergic rhinitis in mice and the anti-asthmatic effect of Cs-4 in a rat model of asthma. Treatment with Cs-4 suppressed the nasal symptoms induced in OVA-sensitized and challenged mice. The inhibition was associated with a reduction in IgE/OVA-IgE and interleukin (IL)-4/IL-13 levels in the nasal fluid. Cs-4 treatment also decreased airway responsiveness and ameliorated the scratching behavior in capsaicin-challenged rats. It also reduced plasma IgE levels, as well as IgE and eosinophil peroxidase levels, in the bronchoalveolar fluid. Cs-4 treatment completely suppressed the increases in IL-4, IL-5, and IL-13 levels in rat lung tissue. In conclusion, our results suggest that Cs-4 has the potential to alleviate immune hypersensitivity reactions in allergic rhinitis and asthma.

The role of inducible costimulatory molecular ligand (ICOSL) in children with neutrophilic asthma

BACKGROUND

It has been shown that certain severe and refractory asthma cases are caused by neutrophil and not eosinophil infiltration. Inducible costimulatory molecular ligand (ICOSL) expression is closely associated with tumor and autoimmune diseases, yet a limited amount of data has been published regarding the significance of ICOSL in children with neutrophilic asthma. The present study aimed to explore the clinical significance of abnormal expression of ICOSL in peripheral blood and bronchoalveolar lavage fluid (BALF) samples of children with neutrophilic asthma.

METHODS

Selected children from the Children's Hospital of Soochow University who met the diagnostic criteria of asthma and excluded patients with a pathogen-positive etiology. Children who were admitted to the hospital for foreign body inhalation in the same period acted as the control group. Children with more than 50% of neutrophils in BALF samples were assigned to the neutrophilic asthma group (NA group), and the remaining subjects composed the asthma group (A group). The expression levels of ICOSL, IL-4, IL-17, IFN-γ, neutrophil elastase (NE), and matrix metalloproteinase-9 (MMP-9) were detected in plasma and BALF samples by enzyme-linked immunosorbent assays, in order to analyze the differences in the levels of cytokines and clinical characteristics between children with neutrophilic asthma and non-neutrophilic asthma. Moreover, the potential mechanism of ICOSL in neutrophilic asthma was explored.

RESULTS

32 children were enrolled: 12 children in the NA group and 20 children in the A group. The mean hospitalization time of the NA group was longer than that of the A group (P<0.05). The concentration levels of ICOSL, IL-17, NE, and MMP-9 in plasma and BALF samples in the NA group were higher than those in the A group, while the levels of IFN-γ exhibited opposite. A significant correlation was found between ICOSL and IL-17 levels in plasma (r=0.753, P=0.012) and BALF (r=0.774, P=0.009) samples in the NA group.

CONCLUSIONS

Children with neutrophilic asthma were more severely affected, experiencing a considerably more difficult clinical treatment and longer hospitalization time. ICOSL may regulate the secretion of IL-17 by Th17 and increase the levels of NE and MMP-9, which are involved in the development of immune inflammation in neutrophils.

Primary care provider preferences for glucocorticoid management of acute asthma exacerbations in children

OBJECTIVE

Primary care providers (PCP) frequently care for children with acute asthma exacerbations in the outpatient setting. The objective of this study is to evaluate PCP preferences and perceptions regarding oral glucocorticoids prescribed from both outpatient primary care and ED settings for the treatment of children with acute asthma exacerbations.

METHODS

PCPs belonging to the Colorado Chapter of the American Academy of Pediatrics were surveyed between February and May 2019. Survey items were generated by a multidisciplinary team and underwent content and criteria validation and pilot testing. Survey items evaluated PCP preferred oral glucocorticoid and dosing regimen for children with acute asthma exacerbations, provider- and patient-level factors contributing to glucocorticoid preferences, and perception of glucocorticoid regimens in terms of treatment failure, resolution of symptoms and adherence.

RESULTS

A total of 109 of 600 (18.2%) PCPs responded. Equal proportions of PCPs reported preferring oral prednisone/prednisolone (50.5%) and oral dexamethasone (49.5%) for children with acute asthma exacerbations. Forty-four percent of PCPs reported no preference in type of glucocorticoid utilized by surrounding emergency departments (EDs). However, for children receiving dexamethasone in the ED but with persistent symptoms on PCP follow-up, 50.5% of PCPs would switch patients to prednisone/prednisolone. PCPs did not perceive more treatment failure or rapid resolution of symptoms with dexamethasone but reported better adherence with dexamethasone.

CONCLUSION

There is variability in PCP glucocorticoid management of pediatric acute asthma exacerbations. There is a need for further investigations to evaluate for differences in clinical outcomes based on PCP glucocorticoid treatment choices.

Oral Dexamethasone vs. Oral Prednisone for Children With Acute Asthma Exacerbations: A Systematic Review and Meta-Analysis

Background: This systematic review and meta-analysis was conducted to compare relapse rates and adverse effects with oral dexamethasone vs. oral prednisone for acute asthma exacerbations in pediatric patients. Methods: A computerized literature search of PubMed, Embase, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials) and Google scholar databases was carried out till 1st August 2019. Six Randomized controlled trials (RCTs) and 1 quasi-RCT were included. Dosage of dexamethasone and prednisone varied across studies. Studies were grouped based on the follow-up period and duration of dexamethasone administration. Results: There was no significant difference in the relapse rate between dexamethasone and prednisone at 1-5 days (RR 1.46, 95%CI 0.69-3.7, P = 0.32; I 2 = 0%) and 10-15 days of follow up (RR 1.16, 95%CI 0.80-1.68, P = 0.44; I 2 = 0%). Pooled analysis found no significant difference in relapse rates with 1-day (RR 1.15, 95%CI 0.68-1.95, P = 0.60; I 2 = 0%) and 2-day dosage of dexamethasone (RR 1.25, 95%CI 0.82-1.92, P = 0.30; I 2 = 0%) compared to prednisone. Hospital readmission rates after initial discharge were not significantly different between the two drugs (RR 1.49, 95%CI 0.56-4.01, P = 0.43; I 2 = 0%). Frequency of vomiting at ED (RR 0.21, 95%CI 0.05-0.96, P = 0.04; I 2 = 50%) and at home (RR 0.42, 95%CI 0.25-0.69, P = 0.0007; I 2 = 0%) was significantly higher with prednisone as compared to dexamethasone. Conclusion: While our results indicate that both dexamethasone and prednisone have similar relapse rates when used for acute asthmatic exacerbations, strong conclusions cannot be drawn due to paucity of large scale RCTs and limited quality of evidence. Dexamethasone is however associated with lower incidence of vomiting as compared to prednisone. Further homogenous RCTs are needed to provide robust evidence on this topic.

Steroid variability in pediatric inpatient asthmatics: survey on provider preferences of dexamethasone versus prednisone

Objective: Our hospital's pediatric Emergency Department (ED) began using dexamethasone for treating asthma exacerbations after ED studies showed non-inferiority of dexamethasone compared to prednisone. However, providers have not reached consensus on optimal inpatient steroid regimen. This study evaluates provider preference for inpatient steroid treatment.Methods: A survey was distributed to providers who care for inpatient pediatric asthmatics. Respondents answered questions about steroid choice and timing. Data were summarized as percentages; bivariate comparisons were analyzed with Pearson's chi-squared test.Results: Ninety-two providers completed the survey (60% response rate). When patients received dexamethasone in the ED, subsequent inpatient management was variable: 44% continued dexamethasone, 14% switched to prednisone, 2% said no additional steroids, and 40% said it depended on the scenario. Hospitalists were more likely to continue dexamethasone than pulmonologists (61% and 15%, respectively; p < .001). Factors that influenced providers to switch to prednisone in the inpatient setting included severity of exacerbation (73%) and asthma history (47%). Fifty-one percent felt uncomfortable using dexamethasone because of "minimal data to support [its] use inpatient." In case-based questions, 28% selected dexamethasone dosing intervals outside the recommended range. Thirteen percent reported experiencing errors in clinical practice.Conclusions: Use of dexamethasone in the ED for asthma exacerbations has led to uncertainty in inpatient steroid prescribing practices. Providers often revert to prednisone, especially in severe asthma exacerbations, possibly due to experience with prednisone and limited research on dexamethasone in the inpatient setting. Further research comparing the effectiveness of dexamethasone to prednisone in inpatient asthmatic children with various severities of illness is needed.