SGEM#375: Only One versus Two-Dose Dexamethasone for Mild to Moderate Pediatric Asthma Exacerbations

Date: August 25th, 2022 Reference: Martin et al. Single-dose dexamethasone is not inferior to 2 doses in mild to moderate pediatric asthma exacerbations in the emergency department. Pediatr Emerg Care. 2022 Dr. Harrison Hayward Guest Skeptic: Dr. Harrison Hayward is a Pediatric Emergency Medicine fellow at Children’s National Hospital. He finished his General Pediatrics residency at Yale-New Haven Hospital. As an editor and writer of continuing medical education material for the clinical case-sharing app, Figure 1, he enjoys interprofessional learning and is passionate about improving health care delivery to children with complex medical needs. Case: A 7-year-old female with asthma presents to the emergency department (ED) with difficulty breathing in the setting of 1-2 days of cough and runny nose. She reports that her albuterol helped her feel better yesterday, but it is providing no relief today. On exam, she has diffuse expiratory wheezing but good aeration to bilateral lung bases with a respiratory rate of 22. She has some intercostal retractions. SpO2 97% on room air. She can speak in full sentences. You diagnose her with a mild asthma exacerbation and begin treating her with albuterol/ipratropium and a dose of dexamethasone. After you explain the plan to the family, her mother says to you, “last time she was here, we got another dose of that steroid medication to take the next day. Do you think she needs it? She doesn’t like taking it, and it makes it hard for her to get to sleep.” Background: Asthma affects around 9% of children in the United States and asthma exacerbations are a common cause for ED visits. Corticosteroids are commonly use for treatment of acute asthma exacerbations. Previous research has compared the efficacy of a multi-day course of prednisone/prednisolone to single dose or two doses of dexamethasone [1-4]. We covered one of these studies on the SGEM: Highway to the Dexamethasone (SGEM #194) “A single dose of dexamethasone is non-inferior to a three-day course of oral prednisolone in the treatment of children with acute asthma exacerbation presenting to the emergency department.” So why are we back here talking about corticosteroids and asthma again? Studies had compared prednisone/prednisolone with one or two-dose dexamethasone. However, no prospective clinical trial has directly compared single dose dexamethasone to two doses. Clinical Question: Is a single dose of dexamethasone non-inferior to two doses of dexamethasone in the treatment of mild to moderate pediatric asthma exacerbations? Reference: Martin et al. Single-dose dexamethasone is not inferior to 2 doses in mild to moderate pediatric asthma exacerbations in the emergency department. Pediatr Emerg Care. 2022 Population: Children aged 2 to 20 years with known history of asthma who presented to the ED between April 2015 and March 2018 with an acute mild (PAS 5-7) or moderate (PAS 8-11) asthma exacerbation. “History of asthma” defined as at least one prior episode of wheezing responsive to beta agonists. Pediatric Asthma Score (PAS) Exclusion: Severe exacerbation (PAS >=12), systemic steroid use in the last two weeks, chronic lung disease (ie cystic fibrosis), or vomiting of two doses oral steroids in the ED Intervention: Two-dose dexamethasone Comparison: Single-dose dexamethasone Outcome: Primary Outcome: Return visits to either the primary care physician/ED/urgent care for persistent asthma symptoms Secondary Outcomes: Length of time symptoms persisted, missed school days, vomiting, adverse events (appetite changes, insomnia, mood swings) Trial: Prospective, randomized, single-center, unblinded, parallel-group randomized clinical trial Authors’ Conclusions: “In this single-center, unblinded randomized trial of children and adolescents with mild to moderate acute exacerbations of asthma, there was no difference in the rate of return visits f...