Comparison between epinephrine and terbutaline injections in the acute management of asthma

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.

Terbutaline and aminophylline as second-line therapies for status asthmaticus in the pediatric intensive care unit

OBJECTIVE

Asthma is the most common chronic disease of childhood. Although asthma admissions to the pediatric intensive care unit (PICU) are increasing, there are no evidence-based guidelines on preferred escalation of therapies for patients with status asthmaticus who fail to respond to inhaled bronchodilators and systemic corticosteroids. The purpose of this study was to assess outcomes of PICU patients receiving aminophylline versus terbutaline as second-tier therapies for status asthmaticus.

DESIGN

Retrospective cohort study using Pediatric Health Information System from 2016-2019.

SETTING

Fifty-three tertiary children's hospitals.

SUBJECTS

Children aged 2 to 18 years admitted to the PICU in children's hospitals contributing data to the Pediatric Health Information System with a primary diagnosis of status asthmaticus.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 11 133 pediatric patients treated for status asthmaticus in the PICU during the study period, 1144 received either terbutaline or aminophylline. There was no difference in intubation and mechanical ventilation between patients who received aminophylline and those who received terbutaline. However, in African American patients, those who received terbutaline had a significantly higher odds of intubation and mechanical ventilation compared to those who received aminophylline (OR, 12.41; 95%CI, 1.61,95).

CONCLUSIONS

The use of aminophylline is associated with lower odds of intubation and mechanical ventilation in African American patients with status asthmaticus as compared to terbutaline.

Evaluation and management of the critically ill adult asthmatic in the emergency department setting

INTRODUCTION

Asthma is a common reason for presentation to the Emergency Department and is associated with significant morbidity and mortality. While patients may have a relatively benign course, there is a subset of patients who present in a critical state and require emergent management.

OBJECTIVE

This narrative review provides evidence-based recommendations for the assessment and management of patients with severe asthma.

DISCUSSION

It is important to consider a broad differential diagnosis for the cause and potential mimics of asthma exacerbation. Once the diagnosis is determined, the majority of the assessment is based upon the clinical examination. First line therapies for severe exacerbations include inhaled short-acting beta agonists, inhaled anticholinergics, intravenous steroids, and magnesium. Additional therapies for refractory cases include parenteral epinephrine or terbutaline, helium‑oxygen mixture, and consideration of ketamine. Intravenous fluids should be administered, as many of these patients are dehydrated and at risk for hypotension if they receive positive pressure ventilatory support. Noninvasive positive pressure ventilation may prevent the need for endotracheal intubation. If mechanical ventilation is required, it is important to avoid breath stacking by setting a low respiratory rate and allowing permissive hypercapnia. Patients with severe asthma exacerbations will require intensive care unit admission.

CONCLUSIONS

This review provides evidence-based recommendations for the assessment and management of severe asthma with a focus on the emergency clinician.

Mechanically Ventilating the Severe Asthmatic

The management of the critically ill patients with asthma can be rather challenging. Potentially devastating complications relating to this presentation include hypoxemia, worsening bronchospasm, pulmonary aspiration, tension pneumothorax, dynamic hyperinflation, hypotension, dysrhythmias, and seizures. In contrast to various other pathologies requiring mechanical ventilation, acute asthma is generally associated with better outcomes. This review serves as a practical guide to the physician managing patients with severe acute asthma requiring mechanical ventilation. In addition to specifics relating to endotracheal intubation, we also discuss the interpretation of ventilator graphics, the recommended mode of ventilation, dynamic hyperinflation, permissive hypercapnia, as well as the role of extracorporeal membrane oxygenation and noninvasive mechanical ventilation.

Addition of intravenous beta(2)-agonists to inhaled beta(2)-agonists for acute asthma

BACKGROUND

Inhaled beta-agonist therapy is central to the management of acute asthma. This review evaluates the benefit of an additional use of intravenous beta(2)-agonist agents.

OBJECTIVES

To determine the benefit of adding intravenous (IV) beta(2)-agonists to inhaled beta(2)-agonist therapy for acute asthma treated in the emergency department.

SEARCH METHODS

Randomised controlled trials (RCTs) were identified using the Cochrane Airways Group Register which is a compilation of systematic searches of MEDLINE, EMBASE, CINAHL, and CENTRAL as well as handsearching of 20 respiratory journals. Bibliographies from included studies and known reviews were also searched. Primary authors and content experts were contacted to identify eligible studies. The search was performed in September 2012.

SELECTION CRITERIA

Only RCTs were considered for inclusion. Studies were included if patients presented to the emergency department with acute asthma and were treated with IV beta(2)-agonists with inhaled beta(2)-agonist therapy and existing standard treatments versus inhaled beta(2)-agonists and existing standard treatments.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and confirmed their findings with corresponding authors of trials. We obtained missing data from authors or calculated from data present in the papers. We used fixed-effect model for odds ratios (OR) and for mean differences (MD) we used both fixed-effect and random-effects models and reported 95% confidence intervals (CI).

MAIN RESULTS

From 109 potentially relevant studies only three (104 patients) met our inclusion criteria: Bogie 2007 (46 children), Browne 1997 (29 children) and Nowak 2010 (29 adults). Bogie 2007 investigated the addition of intravenous terbutaline to high dose nebulised albuterol in children with acute severe asthma, requiring intensive care unit (ICU) admission. Browne 1997 investigated the benefit of adding intravenous salbutamol to inhaled salbutamol in children with acute severe asthma in the emergency department. Nowak 2010 investigated addition of IV bedoradrine to standard care (nebulised albuterol, ipratropium and oral corticosteroids) among adults, and was reported as a conference abstract only.There was no significant advantage (OR 0.29; 95%CI 0.06 to 1.38, one trial, 29 adults) for adding IV bedoradrine to standard care (nebulised albuterol, ipratropium and oral corticosteroids) with regard to hospitalisation rates.Various outcome indicators for the length of stay were reported among the trials. Browne 1997 reported a significantly shorter recovery time (in terms of cessation of 30 minute salbutamol) for children in the IV salbutamol with inhaled salbutamol group (four hours) versus the 11.1 hours for the inhaled salbutamol group (P = 0.03). Time to cessation of hourly nebuliser was also significantly shorter (P = 0.02) for the IV plus inhaled salbutamol group (11.5 hours versus 21.2 hours), and they were ready for emergency patient discharge on average 9.7 hours earlier than the inhaled salbutamol group (P < 0.05). In a paediatric ICU study Bogie 2007 reported no significant advantage in length of paediatric ICU admission (hours) for adding IV terbutaline to nebulised albuterol (MD -12.95, 95% CI: -38.74, 12.84).Browne 1997 reported there were only six out of 14 children with a pulmonary index score above six in the IV plus inhaled salbutamol group at two hours compared with 14 of the 15 in the inhaled salbutamol group (P = 0.02)In Browne 1997 there was a higher proportion of tremor in the IV plus inhaled salbutamol group than in the inhaled salbutamol group (P < 0.02). Nowak 2010 did not report any statistically significant adverse effects associated with adding IV bedoradrine to standard care (nebulised albuterol, ipratropium and oral corticosteroids). Troponin levels were elevated in three children in the IV terbutaline + nebulised albuterol group at 12 and 24 hours in Bogie 2007

AUTHORS' CONCLUSIONS

There is very limited evidence from one study (Browne 1997) to support the use of IV beta(2)-agonists in children with severe acute asthma with respect to shorter recovery time, and similarly there is limited evidence (again from one study Browne 1997) suggesting benefit with regard to pulmonary index scores; however this advantage needs to be considered carefully in relation to the increased side effects associated with IV beta(2)-agonists. We identified no significant benefits for adults with severe acute asthma. Until more, adequately powered, high quality clinical trials in this area are conducted it is not possible to form a robust evaluation of the addition of IV beta(2)-agonists in children or adults with severe acute asthma.

Intravenous beta(2)-agonists versus intravenous aminophylline for acute asthma

BACKGROUND

Inhaled beta(2)-agonist therapy is central to the management of acute asthma. For rapid bronchodilation in severe cases, penetration of inhaled drug to the affected small conducting airway may be impeded, and the intravenous (IV) rather than inhaled administration of bronchodilators may provide an earlier response. IV beta(2)-agonist agents and IV aminophylline may also be considered as additional interventions in this setting and this review compares IV beta-agonist agents and IV aminophylline in the treatment of people with acute asthma.

OBJECTIVES

To compare the benefit of IV beta(2)-agonists versus IV aminophylline for acute asthma treated in the emergency department and in patients admitted to hospital with acute severe asthma.

SEARCH METHODS

Randomised controlled trials (RCTs) were identified using the Cochrane Airways Group Register, which is compiled from systematic searches of bibliographic databases as well as handsearching of respiratory journals and conference abstracts. The latest search was run in September 2012. We searched bibliographies from included studies and known reviews were also searched. Primary authors and content experts were contacted to identify eligible studies.

SELECTION CRITERIA

We included RCTs of patients who presented to the emergency department with acute asthma, and patients admitted to hospital with acute severe asthma, and were treated with IV beta(2)-agonists versus IV aminophylline. Two review authors independently selected potentially relevant articles and selected articles for inclusion. Methodological quality was independently assessed using two scoring systems and two review authors.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two review authors. Missing data were obtained from authors or calculated from data present in the papers. Trials were combined using a random-effects model for odds ratios (OR) or mean differences (MD) and reported with 95% confidence intervals (95% CI).

MAIN RESULTS

Eleven studies met our inclusion criteria and in total they included 350 patients. However, opportunities to combine these studies in meta-analyses were limited by the variations in the range of outcomes reported in the trials.Length of stayTwo studies reported length of stay. They were both paediatric trials (with one in paediatric intensive care unit), and there was no significant difference between the two groups (MD 23.19 hours; 95% CI -2.40 to 48.77 hours; 2 studies; N = 73). Individual separate MD analyses for the two studies also indicated no significant difference between the aminophylline and beta(2)-agonist on this outcome. However, this finding should be interpreted with caution owing to the small number of trials and participants the analysis.Pulmonary functionThere were no significant differences in the sequential or summative pulmonary function demonstrated across the studies.Heart rateData for serial heart rates were reported in three studies at various points from 15 to 60 minutes and in each case there were no significant differences between people in the IV aminophylline or beta(2)-agonist groups. The difference between the two groups with respect to final heart rate was statistically significant (MD 10.00; 95% CI 0.99 to 19.01), although these data are from a single, small study and should be interpreted with caution.Adverse effectsThe analyses for giddiness (OR 59.22; 95% CI 2.80 to 1253.05; 1 study; N = 30), nausea/vomiting (where reported as a combined outcome) (OR 14.18; 95% CI 1.62 to 124.52; 2 studies; N = 96) and nausea (OR 6.53; 95% CI 1.60 to 26.72; 2 studies; N = 49) all significantly favoured beta(2)-agonists. In view of the very small number of studies and number of patients contributing to these analyses these results should be interpreted with caution. A closely related review considering the possible benefits of adding IV aminophylline to beta-agonists in adults with acute asthma also indicates a higher incidence of adverse effects associated with IV aminophylline.

AUTHORS' CONCLUSIONS

In the included RCTs there was no consistent evidence favouring either IV beta(2)-agonists or IV aminophylline for patients with acute asthma. The opportunity to draw clear conclusions is limited by the heterogeneity of outcomes evaluated and the small sample sizes in the included studies. It is recommended that these data should be viewed carefully alongside the conclusions from separate Cochrane reviews comparing IV beta(2)-agonists plus inhaled beta(2)-agonists versus inhaled beta(2)-agonists alone and IV aminophylline plus inhaled beta(2)-agonists versus inhaled beta(2)-agonists alone.

Respiratory distress

Preparation for pediatric pulmonary emergencies in the office setting includes adequate training for all medical staff, properly sized and working equipment, and medications to help alleviate respiratory distress when indicated. Status asthmaticus, viral bronchiolitis, and croup account for the vast majority of respiratory emergencies encountered in the pediatric office setting. Timely application of proven approaches to assessment and treatment of these illnesses can prevent hospitalization, decrease length of hospitalizations, and save lives.

Terbutaline vs albuterol for out-of-hospital respiratory distress: randomized, double-blind trial

OBJECTIVE

To determine the efficacy and safety of single doses of subcutaneous terbutaline (TERB) or nebulized albuterol (ALB) during out-of-hospital treatment for respiratory distress from asthma or chronic obstructive pulmonary disease.

METHODS

Patients aged > 18 years who had respiratory distress were enrolled in a double-placebo, double-blind, randomized trial. Paramedics measured respiratory severity using an empiric score [respiratory rate, wheezing, speech, and peak expiratory flow rate (PEFR)], and the patients rated their own respiratory distress using a visual analog scale (VAS). The patients received O2 plus ALB (2.5 mg) and saline injection (n = 40) or TERB (0.25 mg) and saline aerosol (n = 43).

RESULTS

The groups were similar with respect to age, gender, initial empiric scores (median score 9 for both groups), PEFRs (89 +/- 84 L/min, mean +/- SD, for ALB vs 97 +/- 84 L/min for TERB), and respiratory distress VAS scores. Both groups showed significant improvement in their respiratory distress VAS scores by the time of ED arrival. The ALB group had a greater improvement in respiratory distress VAS score than did the TERB group (p < 0.05). Empiric scores, PEFR scores, and hospital admission frequencies were not significantly different. No complication was observed.

CONCLUSION

The out-of-hospital administration of either aerosolized ALB or subcutaneous TERB reduced respiratory severity. Albuterol provided greater subjective improvement in respiratory distress.