Children with severe asthma presenting to the Emergency Department at the Royal Alexandra Hospital for Children in Sydney, Australia, between May 1997 and November 1998 were studied. Severe asthma was defined as respiratory distress with wheeze, sternal retractions, accessory muscle use, and dyspnea, or any 1 of the following: cyanosis, pulsus paradoxus, altered consciousness, or a silent chest on auscultation. Exclusion criteria were age <12 months, heart disease, lung disease other than asthma, and allergies to study medications. Seventy-seven children were eligible and 55 whose parents consented to participation were randomized.
All randomized children were treated with nebulized salbutamol (Sal) (2.5 mg for children <2 years and 5mg for children >2 years) and then an intravenous (IV) catheter was inserted and 1 mg/kg of methylprednisolone was given. All children initially received the nebulized Sal every 20 minutes for 3 doses during the first study hour. Children were randomized to also receive either 15 μg/kg Sal IV given over 10 minutes as a single bolus (n=21), or IV saline and inhaled ipratropium bromide (IB) 250 μg every 20 minutes (n=19), or IV Sal 15 μg/kg and inhaled IB (250 μg) every 20 minutes (n=15). Children were monitored by continuous pulse oximetry and frequent vital signs were taken. The primary outcomes were mean times to spacing of inhaled Sal treatment (60, 90, 120, and 180 minutes) as well as mean time to discharge from the hospital. Children in the 3 groups had similar age, gender, duration of asthma attack, and presence of atopic features.
Children in the groups who received IV Sal had a significant reduction in the frequency of inhaled Sal therapy compared to the inhaled IB group at 90, 120, and 180 minutes (P=.008). There was no significant difference between the frequency of inhaled Sal in children who received IB + IV Sal compared to children who received only IV Sal. The average time to hospital discharge was 43 hours for the IV Sal group, which was significantly less than for the children in the inhaled IB group (mean 76 hours) (P=.005). The average time to discharge for the IV Sal + inhaled IB group was 58 hours, which did not differ significantly from the IV Sal group.
Treatment for children with severe disease includes very frequent or continuous inhaled β2-adrenergic agonists,1,2 which in the United States is usually continuous, inhaled albuterol. However, the dose of inhaled medications delivered to the lungs is decreased in children with severe airway obstruction. In such patients, systemic administration may offer a more reliable route of drug administration and effect a more rapid improvement. Rapid initial improvement in severe airway obstruction could then enhance delivery of the inhaled therapy.
The authors have shown...