Clinical Progress Note: Care of Children Hospitalized for Acute Asthma Exacerbation

Since the last National Heart, Lung, and Blood Institute’s (NHLBI) guidelines that were released in 2007, additional evidence has emerged in several areas of asthma care.¹ To provide a concise clinical update relevant to the practice of pediatric hospital medicine, we searched PubMed for asthma publications in the last 10 years with a particular focus on articles published in the last 5 years. We used a validated pediatric search filter to identify pediatric studies, MeSH term for “Asthma,” and the following terms: “Clinical Pathways,” “Clinical Protocols,” “Dexamethasone,” and “Albuterol.” From these articles, we identified three areas of emerging evidence supporting practice change relative to the inpatient care of children with asthma, which are summarized in this brief review. This clinical practice update covers the emerging evidence supporting dexamethasone use for acute asthma exacerbations, the shift away from nebulized albuterol toward metered dose inhaler (MDI) albuterol, and the utility of asthma clinical pathways.

In the last decade, emergency departments (EDs) have increasingly prescribed dexamethasone over prednisone because it is noninferior and has a superior side-effect profile, including less vomiting.² However, the evidence for dexamethasone use in hospitalized children lagged behind ED practice change. This led to uncertainty among pediatric hospitalists regarding the most appropriate oral steroid to use, particularly for children who received dexamethasone in the ED prior to admission.³

Several studies have been published to address this gap in the literature. In 2015 Parikh et al. published a multicenter retrospective cohort study of dexamethasone vs prednisone among hospitalized children using the Pediatric Health Information Systems (PHIS) database. ⁴ The authors compared 1,166 patients who received dexamethasone only with a propensity-matched cohort of 1,284 patients receiving only prednisone/prednisolone. Outcomes included the proportion with a length of stay (LOS) greater than 3 days, all-cause readmission at 7 and 30 days, and cost of admission. A greater proportion of patients receiving prednisone/prednisolone had a LOS greater than 3 days when compared with those in the dexamethasone cohort. There were no significant differences in all cause 7- or 30-day readmission. The dexamethasone cohort had statistically significantly lower costs. The authors concluded that dexamethasone may be a viable alternative to prednisone/prednisolone for children admitted for acute asthma exacerbation not requiring admission to the pediatric intensive care unit (PICU).

In 2019, Tyler et al. published a single-center, retrospective, cohort study that used interrupted time series analysis to evaluate outcomes for inpatients with asthma before and after an ED’s protocol was changed to dexamethasone.⁵ Outcomes analyzed included LOS, hospital charges, and PICU transfer rates. The study included 1,015 subjects over a 36-month period. In the post–protocol change group, 65% of the subjects received dexamethasone only while 28% received a combination of dexamethasone and prednisone/prednisolone. The authors found no immediate significant differences in LOS, ICU transfers, or charges after the protocol change. However, they did see an overall 10% increased rate of PICU transfers in the period following the protocol change, a trend that could have been caused by difficult-to-measure differences in severity of patients before and after the protocol change. If the increase in PICU transfer rate was temporally associated with the ED protocol change, an immediate change in rate would be expected, and this was not seen. The authors speculated that dexamethasone may be inferior to prednisone for inpatients with the highest severity of asthma.

Combined with the practical benefit of dexamethasone’s shorter treatment course and decreased vomiting,² these two studies support the use of dexamethasone in the inpatient setting for patients who don’t require ICU level care. A feasibility trial to determine noninferiority of dexamethasone vs prednisone is currently enrolling, according to clinicaltrials.gov.