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Practice patterns in asthma discharge pharmacotherapy in pediatric emergency departments: a pediatric emergency
Suzanne Schuh1, Roger Zemek, Amy Plint
1Department of Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada. suzanne.schuh@sickkids.ca
Insights
Most children with acute asthma receive inhaled albuterol via metered dose inhalers (MDIs) at discharge. However, optimal use of inhaled corticosteroids (ICS) and oral steroids may not be consistently achieved, especially for those not on ICS initially.
Area of Science:
- Pediatric Emergency Medicine
- Respiratory Medicine
- Pharmacotherapy Research
Background:
- Acute asthma management in children requires effective discharge pharmacotherapy.
- Metered dose inhalers (MDIs) with albuterol are standard, but concurrent use of oral and inhaled corticosteroids (ICS) is crucial for comprehensive care.
- Previous studies indicate variability in discharge medication practices for pediatric asthma.
Purpose of the Study:
- To assess the utilization of beta-2 agonists via MDIs, alongside oral and inhaled corticosteroids (ICS), at discharge for children treated for acute asthma.
- To identify factors influencing the prescription of comprehensive asthma therapy in pediatric emergency departments.
Main Methods:
- Retrospective review of medical records from six pediatric emergency departments.
- Inclusion of otherwise healthy children aged 2-17 years discharged with acute asthma.
- Extraction of data on patient history, disease severity, and ED/discharge pharmacotherapy, focusing on albuterol MDI, oral steroids, and ICS.
Main Results:
- 58% of children received "comprehensive therapy" (albuterol MDI with oral and ICS), with significant center variation (30%-84%).
- While 80% received oral steroids and 80% received ICS, only 58% of patients not on ICS at arrival were prescribed ICS at discharge.
- Daytime presentation and intensive stabilization were predictors of comprehensive therapy.
Conclusions:
- The majority of children with acute asthma are discharged on albuterol via MDIs from Canadian pediatric EDs.
- While corticosteroid use is higher than previously reported, optimal utilization of new ICS prescriptions may be suboptimal.
- Children presenting during the day and receiving intensive stabilization are more likely to receive the recommended albuterol/oral steroid/ICS combination therapy.
Objectives:
The objective was to examine utilization of β2 agonists via metered dose inhalers with oral and inhaled corticosteroids (ICS) at discharge in children with acute asthma.
Methods:
This was a retrospective medical record review at six pediatric emergency departments (EDs) of otherwise healthy children 2 to 17 years of age discharged with acute asthma. Data were extracted on history, disease severity, and pharmacotherapy used in the ED and at discharge. The primary outcome was the proportion of children prescribed "comprehensive therapy," i.e., albuterol via metered dose inhaler (MDI) with oral and ICS.
Results:
The overall rate of comprehensive therapy was 382 of 654 (58%), which varied from 30% to 84% (p < 0.0001). A total of 570 of 575 children discharged on albuterol received MDIs. Although the rates of prescriptions for oral and ICS were both 80%, only 58% of patients without ICS on arrival were offered ICS at discharge. There was significant variation in the rates of all discharge pharmacotherapies across centers. The independent predictors of comprehensive therapy were daytime presentation (odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.05 to 2.67) and "intensive stabilization" (OR = 2.33, 95% CI = 1.29 to 2.67). Seventeen patients (2.6%) were prescribed antibiotics. Children were more likely to receive antibiotics if they had moderate to severe exacerbations (OR = 2.8) or received a chest radiograph (OR = 8.4).
Conclusions:
The overwhelming majority of children discharged from Canadian pediatric EDs with acute asthma are prescribed inhaled albuterol via MDIs. Although the corticosteroid use at discharge is higher than previously reported, utilization of new prescriptions for ICS may not be optimal. Children presenting during daytime to EDs receiving intensive stabilization are more likely to receive the albuterol/oral steroid/ICS combination.
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