PURPOSE OF THE STUDY.
The goal of the study was to test the hypothesis that adding high-dose nebulized budesonide to standard asthma treatment in children in the emergency department (ED) during the first hour would decrease their hospital admission rate.
The study population included children aged 2 to 12 years with physician-diagnosed asthma (or previous episodes of shortness of breath responsive to a β-agonist) who presented to the ED with a moderate or severe acute asthma exacerbation.
Children were randomized within the pharmacy (double-blind) to receive 3 doses of 500 μg/dose of budesonide or placebo with a β-agonist (salbutamol + ipratropium bromide) via nebulization every 20 minutes over 1 hour. They also received prednisolone 2 mg/kg (maximum dose of 60 mg). Asthma severity was assessed by using a previously studied asthma scoring system. Patients were assessed at baseline and 1 and 2 hours after initiation of medication. Those who remained in the ED were also evaluated at 3 and 4 hours. A decision to admit or discharge was made at 2, 3, or 4 hours.
The study enrolled 723 children, with 139 re-enrolled at subsequent visits for a total of 906 randomization assignments. Overall, there was no statistical difference in admission rates, with 16.4% of the budesonide group versus 18.3% of the placebo group admitted (P = .38). On subgroup analysis, however, among the more severe group, significantly fewer children in the budesonide group were admitted versus the placebo group (P = .03). Among the subgroup with severe asthma, there was a 58% reduction in the risk of admission in the budesonide group versus the placebo group.
The addition of nebulized budesonide to standard ED treatment decreased admission rates in children with severe acute asthma.
Most ED protocols for acute asthma incorporate oral steroids in addition to bronchodilators (albuterol + ipratropium bromide). This study examined whether adding inhaled corticosteroids would decrease admission rates. Despite no change in admission rates in the full study population, a decrease in the severe group shows that adding inhaled budesonide may help the group of children with the highest risk of admission. Although it would require treating 7 patients to save 1 admission, this approach would be cost-effective compared with the cost of hospitalization. Using inhaled steroids in the ED also reinforces the role of inhaled steroids in the chronic management of asthma.
- Copyright © 2014 by the American Academy of Pediatrics