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Correspondence |

The Dilemma of Albuterol Dosing for Acute Asthma Exacerbations in Pediatric Patients FREE TO VIEW

Donald H. Arnold, MD, MPH; Paul E. Moore, MD; Thomas J. Abramo, MD; Tina V. Hartert, MD, MPH
Author and Funding Information

From the Department of Pediatrics, Division of Emergency Medicine (Drs Arnold and Abramo), the Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine (Dr Moore), the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (Dr Hartert), and the Center for Asthma Research (Drs Arnold and Hartert), Vanderbilt University School of Medicine.

Correspondence to: Donald H. Arnold, MD, MPH, Rm 1014, Vanderbilt Children’s Hospital, Nashville, TN 37232; e-mail: don.arnold@vanderbilt.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Moore served in the speaker’s bureau for Merck from July 2008 to June 2009. He also received a research grant from Asklepion Pharmaceuticals for a clinical trial of a medication for asthma. Drs Arnold, Moore, and Hartert currently receive National Institutes of Health support for research grants. Dr Abramo has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(2):472. doi:10.1378/chest.10-2163
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Inhaled albuterol is a first-line treatment of acute asthma exacerbations. Nebulized albuterol doses recommended by expert consensus guidelines for exacerbations in children ≤ 12 years of age are “0.15-0.3 mg/kg up to 10 mg every 1-4 hours as needed, or 0.5 mg/kg/hour by continuous nebulization.”1 Although the benefit of continuous treatment is well established, we can find only one, small randomized controlled trial (N = 33) that compared the recommended guideline continuous nebulized albuterol (CNA) dose (10 mg/h) with a lower dose, a level of evidence meeting at best grade B2.2-4 We are not aware of evidence to support even higher doses, and there has long been concern about the disparity of doses used for these episodes.3 With this in mind, we sought to examine the doses of CNA currently in use for pediatric patients with moderate and severe asthma exacerbations managed in pediatric EDs.

We administered an Internet-based questionnaire to respiratory care directors of the Child Health Corporation of America, a network of 43 children’s hospitals. The questionnaire consisted of 10 questions on albuterol treatment decisions for pediatric patients with acute asthma exacerbations managed in the ED. The questionnaire was distributed three times at 3-week intervals, and duplicate responses were excluded. The study protocol and questionnaire were approved by the Vanderbilt University Human Research Protection Program (protocol #091569), and completion of the questionnaire implied consent.

Responses were received from 22 (51%) of eligible participants. All respondents were from a pediatric-specific ED. CNA dosing was determined by institutional protocol for 16 (76%) of 21 respondents completing the question, and percent predicted peak expiratory flow or FEV1 were used to guide CNA treatment at seven (33%) of these 21 institutions. For moderate-severity exacerbations, six (60%) of 10 completing the question reported using CNA doses that exceed current expert guidelines. All respondents reported exceeding guideline CNA doses for severe exacerbations, with three (33%) of nine who responded using 25 mg/h. There was no limit on duration of CNA treatment at 18 (82%) of the 22 institutions.

These children’s hospital respiratory care directors report using CNA doses and treatment durations that frequently exceed those recommended by expert guidelines, creating a potential dilemma between the guidelines and what appears to be frequent clinical practice for pediatric patients. For this reason, and because current expert guidelines may be informed by limited evidence, further investigations are warranted of albuterol doses and treatment duration recommended by these guidelines and, in particular, of higher doses frequently used in clinical practice.

Author contributions:Dr Arnold: contributed to the study design and enrolling participants and is the primary author of this work.

Dr Moore: contributed to manuscript preparation.

Dr Abramo: contributed to manuscript preparation.

Dr Hartert: contributed to study design and manuscript preparation and serves as Dr Arnold’s NHLBI Career Development Award mentor.

National Heart, Lung, and Blood InstituteNational Heart, Lung, and Blood Institute Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. 2007; Washington, DC US Department of Health and Human Services. National Institutes of Health National Heart, Lung, and Blood Institute
 
Camargo CA Jr, Spooner CH, Rowe BH. Continuous versus intermittent beta-agonists in the treatment of acute asthma. Cochrane Database Syst Rev. 2003;4:CD001115
 
Schuh S, Reider MJ, Canny G, et al. Nebulized albuterol in acute childhood asthma: comparison of two doses. Pediatrics. 1990;864:509-513. [PubMed]
 
Guyatt GH, Sackett DL, Sinclair JC, Hayward R, Cook DJ, Cook RJ. Evidence-Based Medicine Working Group Evidence-Based Medicine Working Group Users’ guides to the medical literature. IX. A method for grading health care recommendations. JAMA. 1995;27422:1800-1804. [CrossRef] [PubMed]
 

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References

National Heart, Lung, and Blood InstituteNational Heart, Lung, and Blood Institute Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. 2007; Washington, DC US Department of Health and Human Services. National Institutes of Health National Heart, Lung, and Blood Institute
 
Camargo CA Jr, Spooner CH, Rowe BH. Continuous versus intermittent beta-agonists in the treatment of acute asthma. Cochrane Database Syst Rev. 2003;4:CD001115
 
Schuh S, Reider MJ, Canny G, et al. Nebulized albuterol in acute childhood asthma: comparison of two doses. Pediatrics. 1990;864:509-513. [PubMed]
 
Guyatt GH, Sackett DL, Sinclair JC, Hayward R, Cook DJ, Cook RJ. Evidence-Based Medicine Working Group Evidence-Based Medicine Working Group Users’ guides to the medical literature. IX. A method for grading health care recommendations. JAMA. 1995;27422:1800-1804. [CrossRef] [PubMed]
 
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