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. 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 TimeVomitHR Spacer66 9% + 5% Nebulizer103 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. 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 !!