Controversies in the ED Management of Acute Asthma

1. Controversies in the ED Management of Acute Asthma Fahad al Hammad Martin V. Pusic Children’s & Women’s Health Centre

2. Case - Asthma A 4-year old known asthmatic presents in moderate-severe distress. Therapy is initiated.

3. Therapy • Spacer versus Nebulizer • Timing of Steroids • Ipratropium bromide

4. Therapy • Spacer versus Nebulizer • Timing of Steroids • Ipratropium bromide

5. Spacers vs. Nebulizers • July 2001 Cochrane Review • 16 studies: 686 children and 375 adults

6. Spacers vs. Nebulizers • No difference in admission rate • 95% CI ( OR: 0.4 to 2.1 ) • Children’s LOS in the ED shorter • mean diff: -0.62 hours • 95% CI ( -0.84 to -0.40 ) • No difference for LOS in adults

7. Spacers vs. Nebulizers

8. Spacers vs. Nebulizers Key Study: • Chou, Cunningham, Crain • APAM 1995

9. Spacers vs. Nebulizers Chou, Cunningham, Crain • 152 patients > 2 years old • 3 puffs q20’ w aerochamber • 0.15mg/kg Ventolin via nebulizer

10. Spacers vs. Nebulizers Chou, Cunningham, Crain • Convenience sample • Unblinded • Steroids given in ED: • 54% Nebulizer group • 76% in Spacer group

11. Spacers vs Nebulizers Time Vomit HR Spacer 66 9% + 5% Nebulizer 103 20% +15%

12. Therapy • Spacer versus Nebulizer • Timing of Steroids • Ipratropium bromide

13. Steroids • Cochrane Review: May 2001 • 12 Studies: • 863 Patients • 409 Pediatric • Main outcome: need for admission

14. Steroids

15. Steroids Number needed to treat with steroids in the first hour to prevent one admission:

16. Steroids Number needed to treat with steroids in the first hour to prevent one admission: 6

17. Steroids Number needed to treat with steroids in the first hour to prevent one admission: 6

18. Therapy • Spacer versus Nebulizer • Timing of Steroids • Ipratropium bromide

19. Ipratropium • May 2001 Cochrane Review • 8 studies - considerable heterogeneity

20. Ipratropium bromide • Single dose does not work • Multiple dose decreases admissions • NNT 12 overall 95% CI ( 8, 32 ) • NNT 7 severe subgroup 95% CI ( 5,20 )

21. Ipratropium - Admissions

22. Qureshi et al. • Randomized Controlled Trial • 3 doses of IB vs. Placebo • Admission decision at 2-3 hours • Showed marked decrease in admission rates

23. Qureshi et al.

24. Zorc • Randomized controlled trial • 3 doses of IB vs. Placebo • Admission decision at 4 hours • No difference in admission rate • ED Stay decreased by 23 min. • Over 4 hours need 1 fewer ventolin

25. Zorc

26. Case - Asthma However, over the next hour he gets worse - sats in low 90’s - laboured breathing - ICU consulted Further therapy instituted. Ultimately transferred to the ICU

27. Therapy • Magnesium Sulphate • Theophylline • IV Salbutamol

28. Magnesium • Cochrane Review: May 2001 • 7 trials: 5 adult 2 pediatric • 665 patients (78 pediatric)

29. Magnesium • Outcome -- Admission Rate • No benefit when all patients treated • Severe sub-group showed marked significant benefit (90% --> 48% adm)

30. Magnesium - Admissions

31. Magnesium • Dose: 25-100 mg/kg over 20’ • Max: 2 grams • Obstetrics: 4-5 grams IV load + 10 g IM

32. Magnesium - Harm?

33. Magnesium Key Study: Ciarallo, Sauer, Shannon • RCT - double-blind • Pediatric ED; Age 6-18 years • PEFR < 60% after 3 albuterol masks • MgSO4: 25mg/kg over 20’ iv

34. Magnesium FEV1  FEV1 Adm 50’ 110’ Placebo -1% +5% 16/16 MgSO4 +34% +75% 11/15

35. Magnesium

36. Summary • Spacers -- just as good as Nebulizers

37. Summary • Spacers -- just as good as Nebulizers • Steroids -- good evidence to give in the first hour

38. Summary • Spacers -- just as good as Nebulizers • Steroids -- good evidence to give in the first hour • Ipratropium -- use multiple doses in mod-severe cases

39. Summary • Spacers -- just as good as Nebulizers • Steroids -- good evidence to give in the first hour • Ipratropium -- use multiple doses in mod-severe cases • Magnesium -- use in severe cases

40. Thank You !!