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Inhaled short-acting bronchodilators for managing emergency childhood asthma: an overview of reviews
M Pollock1, I P Sinha2, L Hartling1
1Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
Insights
Short-acting beta-agonists (SABAs) effectively treat childhood wheezing in the emergency department. Adding short-acting anticholinergics (SAACs) helps severe cases in older children, but other treatments are not recommended.
Area of Science:
- Pediatric Emergency Medicine
- Pharmacology
- Respiratory Medicine
Background:
- Conflicting international guidelines exist for managing acute childhood wheezing in emergency departments (EDs).
- Variations in clinical practice suggest uncertainty regarding evidence-based bronchodilator use.
- This study addresses the need for a synthesized evidence overview.
Purpose of the Study:
- To synthesize and appraise all systematic review evidence on inhaled short-acting bronchodilator efficacy and safety.
- To evaluate treatments for asthma and wheeze exacerbations in children (0-18 years) in the ED.
- To inform clinical practice and guideline development.
Main Methods:
- Conducted an overview of systematic reviews (SRs) using Cochrane Collaboration methods.
- Included 13 SRs encompassing 56 trials and 5526 pediatric patients.
- Performed comprehensive literature searching, data extraction, and quality assessment.
Main Results:
- Metered-dose inhaler delivered short-acting beta-agonists (SABAs) are effective first-line therapy, reducing hospital admission (44% in younger children) and ED stay (33 min in older children).
- Adding short-acting anticholinergics (SAACs) to SABAs is beneficial for severe cases in older children, significantly decreasing hospital admissions.
- Continuous nebulization, magnesium sulfate addition, and levosalbutamol over salbutamol are not recommended for routine use.
Conclusions:
- SABAs are a cornerstone of ED management for pediatric acute wheezing.
- Combination therapy with SAACs is indicated for severe exacerbations in older children.
- Current evidence does not support routine use of continuous nebulization, magnesium sulfate, or levosalbutamol in this setting.
Abstract:
International guidelines provide conflicting recommendations on how to use bronchodilators to manage childhood acute wheezing conditions in the emergency department (ED), and there is variation within and among countries in how these conditions are managed. This may be reflective of uncertainty about the evidence. This overview of systematic reviews (SRs) aimed to synthesize, appraise, and present all SR evidence on the efficacy and safety of inhaled short-acting bronchodilators to treat asthma and wheeze exacerbations in children 0-18 years presenting to the ED. Searching, review selection, data extraction and analysis, and quality assessments were conducted using methods recommended by The Cochrane Collaboration. Thirteen SRs containing 56 relevant trials and 5526 patients were included. Results demonstrate the efficacy of short-acting beta-agonist (SABA) delivered by metered-dose inhaler as first-line therapy for younger and older children (hospital admission decreased by 44% in younger children, and ED length of stay decreased by 33 min in older children). Short-acting anticholinergic (SAAC) should be added to SABA for older children in severe cases (hospital admission decreased by 27% and 74% when compared to SABA and SAAC alone, respectively). Continuous nebulization, addition of magnesium sulfate to SABA, and levosalbutamol compared to salbutamol cannot be recommended in routine practice.
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