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Efficacy of IV theophylline in children with severe status asthmaticus
R S Ream1, L L Loftis, G M Albers
1Division of Critical Care, Saint Louis University and the Cardinal Glennon Pediatric Research Institute, St. Louis, MO, USA. reamrs@slu.edu
Insights
Adding intravenous theophylline to standard treatments safely hastened recovery for children with severe asthma attacks. This finding suggests re-evaluating theophylline
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Medicine
- Pharmacology
Background:
- Severe status asthmaticus in children requires aggressive treatment in the pediatric intensive care unit (PICU).
- Standard therapy includes inhaled beta-agonists, inhaled ipratropium, and intravenous methylprednisolone.
- The potential benefit of adjunctive intravenous theophylline requires further investigation.
Purpose of the Study:
- To evaluate the efficacy of adding intravenous theophylline to standard intensive care for severe pediatric status asthmaticus.
- To determine if theophylline improves recovery time in critically ill asthmatic children.
Main Methods:
- Prospective, randomized, controlled trial conducted in a pediatric intensive care unit.
- Participants were children with severe status asthmaticus (Clinical Asthma Score >= 5).
- Interventions included standard therapy plus either intravenous theophylline or placebo, with blinded asthma scoring.
Main Results:
- Theophylline significantly hastened recovery (Clinical Asthma Score <= 3) in non-mechanically ventilated children (18.6 vs. 31.1 hours, p < 0.05).
- No significant effect on overall PICU length of stay or total side effects was observed.
- Theophylline group experienced more emesis, while the control group had more tremor.
Conclusions:
- Intravenous theophylline, when added to aggressive standard care, safely accelerates recovery in children with severe status asthmaticus.
- Theophylline's role in managing pediatric asthma nearing respiratory failure warrants re-examination.
Study Objective:
To determine whether adding IV theophylline to an aggressive regimen of inhaled and IV beta-agonists, inhaled ipratropium, and IV methylprednisolone would enhance the recovery of children with severe status asthmaticus admitted to the pediatric ICU (PICU).
Design:
A prospective, randomized, controlled trial. Asthma scoring was performed by investigators not involved in treatment decisions and blinded to group assignment.
Setting:
The PICU of an urban, university-affiliated, tertiary-care children's hospital.
Patients:
Children with a diagnosis of status asthmaticus who were admitted to the PICU for < or = 2 h and who were in severe distress, as indicated by a modified Wood-Downes clinical asthma score (CAS) of > or = 5.
Interventions:
All subjects initially received continuous albuterol nebulizations; intermittent, inhaled ipratropium; and IV methylprednisolone. The theophylline group was also administered infusions of IV theophylline to achieve serum concentrations of 12 to 17 microg/mL. A CAS was tabulated twice daily.
Measurements And Results:
Forty-seven children (median age, 8.3 years; range, 13 months to 17 years) completed the study. Twenty-three children received theophylline. The baseline CASs of both groups were similar and included three subjects receiving mechanical ventilation in each group. All subjects receiving mechanical ventilation and theophylline were intubated before drug infusion. Among the 41 subjects who were not receiving mechanical ventilation, those receiving theophylline achieved a CAS of < or = 3 sooner than control subjects (18.6 +/- 2.7 h vs 31.1 +/- 4.5 h; p < 0.05). Theophylline had no effect on the length of PICU stay or the total incidence of side effects. Subjects receiving theophylline had more emesis (p < 0.05), and control patients had more tremor (p < 0.05).
Conclusions:
Theophylline safely hastened the recovery of children in severe status asthmaticus who were also receiving albuterol, ipratropium, and methylprednisolone. The role of theophylline in the management of asthmatic children in impending respiratory failure should be reexamined.
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