Pediatric Critical Care Medicine. 2013; 14(5):467-70.

Corticosteroid Therapy in Critically Ill Pediatric Asthmatic Patients.

Giuliano Jr. JS, Faustino EVS, Li S, Pinto MG, Canarie MF, Carroll CL for the Northeast Pediatric Critical Care Research Consortium (NEPCCRC).

Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA.

 

Abstract:

OBJECTIVES: IV corticosteroids are routinely prescribed to treat critically ill children with asthma. However, no specific dosing recommendations have been made for children admitted to the PICU. We aim to determine current asthma corticosteroid dosing preferences in PICUs within North America.

DESIGN: Cross-sectional, self-administered survey.

SETTING: North American PICUs.

SUBJECTS: Pediatric intensivists working in the United States and Canada.

INTERVENTIONS: None

MEASUREMENTS AND MAIN RESULTS: A total of 104 intensivists completed the survey. Of these, 70% worked in the United States, 67% attended in PICUs with at most 20 beds, and 79% had more than 10 years of PICU experience. The majority of asthmatics were admitted to PICUs based on clinical asthma exam/score or because the patient was receiving continuous albuterol. IV methylprednisolone is prescribed by the large majority of intensivists (96%). Of those who prescribe methylprednisolone, 66% use a starting dose of 4 mg/kg/day, whereas 31% use a starting dose of 2 mg/kg/day, and only 3% use 1 mg/kg/day. The large majority of respondents (85%) use “clinical experience” as their rationale for their preferred dosage. In multivariate logistic regression analysis, only knowledge of the National Heart, Lung and Blood Institute (NHLBI) guidelines was an independent predictor of prescribing an initial corticosteroid dose of 4 mg/kg/day (OR: 3.69, 95% CI: 1.26-10.80; p=0.017). Country of practice, years of experience and PICU size were not associated with corticosteroid dosing preference.

CONCLUSIONS: Most intensivists administer methylprednisolone to critically ill asthmatics at doses 2-4 times higher than recommended by the National Heart, Lung, Blood Institute guidelines for hospitalized asthmatic children. The rationale for these decisions is likely multifactorial, but in the absence of evidence-based data, most cite clinical experience as their deciding factor. Future research is needed to determine the most appropriate corticosteroid dosage in this critically ill patient population.

PMID: 23628833

 

Supplement:

Pediatric patients with asthma continue to fill children’s hospitals in the United States. Asthma is currently the most common reason for pediatric admission, stressing the health care system with countless emergency room visits and outpatient health care costs. Without a clear consensus definition in children, the incidence of pediatric asthma is difficult to estimate. However, many experts in the field believe that the number of children diagnosed with asthma is increasing worldwide.

Status asthmaticus, or an acute severe exacerbation unresponsive to rescue bronchodilators, is a common reason for admission to the pediatric intensive care unit (PICU). Though pediatric mortality rates due to asthma continue to remain low, complications from the disease and the incidence of status asthmaticus are increasing in certain pediatric populations. Many authors have attempted to describe which patients are more likely to develop severe morbidity or mortality from an asthma exacerbation (Table 1) (1). Unfortunately, this list is incomplete since some children who die from asthma do not fit into these categories. Because of this, many physicians have adopted an aggressive approach to severe asthma treatment in children.

The pathophysiology of asthma includes two primary features, inflammation and lower airway hyper-responsiveness. Children typically present after exposure to an allergen (i.e. trigger) that results in increased edema, mucus production, bronchospasm, and air trapping. Classically, high- pitched wheezing is heard as air is exhaled (or inhaled in severe cases) through narrowed bronchi due to excessive airway inflammation and smooth muscle hyper-responsiveness to the allergen.

Inflammation plays a key role as well and many inflammatory cells have been identified in the bronchoalveolar lavage fluid of asthmatics, including mast cells, macrophages, B and T lymphocytes, and neutrophils (2).

Systemic corticosteroids have become one of the cornerstones of therapy for status asthmaticus. Unfortunately, dosing guidelines and recommendations have not addressed the needs of the growing population of children admitted to PICUs with asthma. Therefore, we aimed to determine dosing preferences of pediatric intensivists in both Canada and the United States knowing that evidence is lacking. We thought that there would be significant variability in the medication choice and also dose prescribed.

We were surprised to discover that nearly 100% of the respondents were prescribing intravenous methylprednisolone. Since recent studies have shown similar outcomes in children receiving intramuscular dexamethasone, we thought that some PICU attendings would have adopted intravenous dexamethasone into their practice (3). Additionally, we found that two-thirds of the respondents, including ourselves, were prescribing doses 2-4 times what was recommended by the National Asthma Education and Prevention Program. The rationales for these decisions were unclear. Though only a speculation, we think that most pediatric intensivists practice on the assumption that critically ill asthmatic patients should be treated quickly and aggressively. This belief, thus justifies the higher dose of corticosteroids. However, high dose corticosteroids are not benign medications and can result in significant side effects. Limiting these side effects while continuing to treat critically ill asthmatic children aggressively, should be investigated further.

The importance of this study is two-fold. First, it describes the landscape of corticosteroid prescribing practices for critically ill asthmatic children in Canada and the United States. Since almost all pediatric intensivists prefer to use methylprednisolone, a clinical trial to determine an appropriate methylprednisolone dosing regimen could be acceptable to most pediatric intensivists.

Second, with one-third of the responding pediatric intensivists prescribing 2 mg/kg/day and the remaining two-thirds prescribing 4 mg/kg/day, there appears to still be equipoise for a clinical trial. Whether or not a clinical trial is conducted, this study should lend the asthma guideline authors some much needed data pertaining to critically ill asthmatic children when publishing the next guideline iteration. John S Giuliano-table 1

References

1.Werner HA. Status asthmaticus in children: a review. Chest 2001;119(6):1913-1929.

2.Gerblich AA, Salik H, Schuyler MR. Dynamic T-cell changes in peripheral blood and bronchoalveolar lavage after antigen bronchoprovocation in asthmatics. Am Rev Respir Dis 1991;143(3):533-537.

3.Klig JE, Hodge D, 3rd, Rutherford MW. Symptomatic improvement following emergency department management of asthma: a pilot study of intramuscular dexamethasone versus oral prednisone. J Asthma 1997;34(5):419-425.

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