You could go ahead and pick out a good book this summer. But why waste time on formulaic plots and slapdash characterizations when you could be reading great articles relevant to the Pediatric Emergency Department. Here’s another paper from the PEMBlog Summer Reading List!

Quareshi et al.
NEJM. 1998 Oct 8;339(15):1030-5.

What this article is about?

This is a randomized controlled trial 434 children with moderate to severe asthma exacerbations treated in the emergency department. Here is how it was designed from the patient perspective;

  • All patients received one nebulized albuterol (2.5 or 5 mg per dose, depending on body weight) every 20 minutes for three doses
  • A corticosteroid (2 mg/kg prednisone or prednisolone) was given orally with the second dose of albuterol
  • Children in the treatment group received 500 μg (2.5 ml) of ipratropium bromide with the second and third doses of albuterol
  • Children in the control group received 2.5 ml of normal saline with the second and third doses of albuterol

Why is it important?

This article is one of the main reasons why you give duonebs (albuterol/ipratropium) in the Emergency Department in patients with asthma exacerbations. It was an example of a RCT that altered how we practice. Note that this was written A. in the era when we gave 2 mg/kg prednisone (now we only give 1 mg/kg/day or dexamethasone) and B. when I was in college. Overall the authors noted that:

  • The rate of hospitalization was lower in the ipratropium group (59/215 = 27.4%) vs the control group (80/219 =36.5%, P=0.05)
  • In moderate asthma (Peak Flow 50-70% expected or asthma score 8-11/15) hospitalization rates were similar in the two groups – ipratropium: 8/79=10.1%; control: 9/84=10.7%
  • In severe asthma (Peak Flow <50% expected or asthma score 12-15) ipratropium significantly reduced the need for hospitalization (51/136=37.5% vs 71/135=52.6%; P=0.02

How you can use it in your practice

So interestingly some institutions give 3 back to back duonebs as opposed to Albuterol then Duoneb x2. There are reasons for this, many related to the electronic medical record. In my mind, iprotropium has a long enough half-life, and the cost difference is negligible that this is OK. But yes, the “pure” version from the RCT is different than practice. So, from this article you can intone that a reaonsable approach to asthma in the ED would be:

  1. Assess asthma severity
  2. For moderate to severe patients give an albuterol treatment (or duoneb)
    1. If the patient normalizes stop there
    2. If they have not improved give two more duonebs and an oral steroid

You can also use this article as a great way to teach how to critically appraise an RCT. It is a relatable example, and it makes the EBM math very easy.