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Dr Simon Craig
An Australian study has found widespread variation in hospital management strategies for children with severe asthma who require escalated treatment beyond inhaled bronchodilators and oral corticosteroids.
The multicentre study of over 14,000 children presenting with acute severe asthma at 18 hospitals in Australia and New Zealand identified considerable inter-hospital differences in the frequency of treatment escalation and the choice of escalation treatments. It also found that many of the treatments were not supported by high quality evidence.
Overall, 7.3% children with acute severe asthma received some form of escalated treatment, with 4.2% receiving parenteral bronchodilators and 4.3% respiratory support. However, the use of parenteral treatment varied eight-fold between hospitals and the use of respiratory support varied ten-fold between hospitals.
The study investigators said that ‘remarkably’ nasal high-flow (NHF) therapy was used in nearly all patients (99%) who received respiratory support and accounted for nearly one-third of all escalation of asthma treatment.
While there is high-quality evidence supporting NHF therapy as a rescue treatment in children under one year old with bronchiolitis, there is little evidence to guide NHF therapy in children over one year of age with asthma and wheeze, they said.
The most common intravenous medication regimens were: magnesium alone (50.4%), magnesium and aminophylline (24.6%) and magnesium and salbutamol (10.0%).
The study authors said lack of high quality evidence for escalated treatments and inconsistencies with locals guidelines might explain the wide variations seen between hospitals
“While magnesium and salbutamol are listed as second-line and third-line bronchodilators for management of acute severe paediatric asthma in Australian national guidelines, some state-based guidelines prefer magnesium and aminophylline,” they noted
Paediatric respiratory physician and member of the National Asthma Council Australia Guidelines Committee Dr Louisa Owens said this was a critical study as children still die from acute asthma in Australia.