Re: Conflicting asthma guidelines cause confusion in primary care
Mark Levy and colleagues have prompted an important debate which I have followed with interest as a GP with a longstanding clinical and educational interest in paediatric asthma. Our local paediatric units have for five years advocated a SABA weaning regimen similar to that described by James Paton and colleagues, without problems or adverse outcomes that I am aware of. Since acute wheezing episodes resolve gradually not suddenly it has never struck me as sensible to abruptly reduce bronchodilator dosage on discharge from hospital. Adequate length of hospital stay, concomitant appropriate use of inhaled or oral corticosteroids, clear safety netting advice and easy return access to hospital or urgent primary care reassessment are all necessary to maximise the safety of hospital discharge and early follow up in primary care should occur. Failings can and do occur in all these aspects of hospital and post hospital care, but giving unclear advice about how to use bronchodilators after discharge does not make such failings less likely.
Of the three studies cited by Levy and colleagues in their reply, two are inpatient studies in adults (1,2) while the third (3) is an RCT in children of giving versus not giving written self management plans after ED attendance. The post hospital bronchodilator regimen was the same in the two groups. Children with written self management plans did better. Thus we do not have evidence on the relative merits of different bronchodilator regimens for post-hospital treatment.
Avoiding failure to recognise deterioration of asthma control is best addressed by giving good clear safety netting advice.
As for toxicity, salbutamol in the acute setting is a remarkably safe drug. In the past wheezing children were given oral salbutamol in a dose of 2mg (equivalent to 20 puffs from an MDI) three times daily. This is no longer done since the inhaled route is preferable and allows lower dosage but significant safety concerns did not arise. Large numbers of children are given repeated high dose salbutamol in hospital without evidence of harm.
Regular long term over-use of salbutamol is a marker of non compliance with prophylactic treatment and a risk factor for hospital admission and death. But there is a risk that in the minds of both health professionals and parents awareness of this may create unjustified concerns about the safety of using the high doses that are necessary in an exacerbation.
If we are looking for reasons for the unacceptably high mortality from asthma in children and young people in the UK, and for unnecessarily high admission and re-admission rates, we need also to consider that good patient education is crucial for effective asthma care. One feature of our relative underinvestment in health services is that waiting time for consultations is longer and consultation times for primary care professionals are shorter than in most countries of comparable economic status.
Duncan Keeley
Dr Duncan Keeley
General practitioner
Thame OX9 3JF
References
1. Bradding P, Rushby I, Scullion J and Morgan MD, As-required versus regular nebulized salbutamol for the treatment of acute severe asthma. Eur Respir J, 1999; 13: 290-4.
2. Chandra A, Shim C, Cohen HW, et al., Regular vs ad-lib albuterol for patients hospitalized with acute asthma. Chest, 2005; 128: 1115-20.
3. Ducharme FM, Zemek RL, Chalut D, McGillivray D, Noya FJD, Resendes S, et al. Written Action Plan in Pediatric Emergency Room Improves Asthma Prescribing, Adherence, and Control. American Journal of Respiratory and Critical Care Medicine. 2011;183(2):195-203.
Rapid Response:
Re: Conflicting asthma guidelines cause confusion in primary care
Mark Levy and colleagues have prompted an important debate which I have followed with interest as a GP with a longstanding clinical and educational interest in paediatric asthma. Our local paediatric units have for five years advocated a SABA weaning regimen similar to that described by James Paton and colleagues, without problems or adverse outcomes that I am aware of. Since acute wheezing episodes resolve gradually not suddenly it has never struck me as sensible to abruptly reduce bronchodilator dosage on discharge from hospital. Adequate length of hospital stay, concomitant appropriate use of inhaled or oral corticosteroids, clear safety netting advice and easy return access to hospital or urgent primary care reassessment are all necessary to maximise the safety of hospital discharge and early follow up in primary care should occur. Failings can and do occur in all these aspects of hospital and post hospital care, but giving unclear advice about how to use bronchodilators after discharge does not make such failings less likely.
Of the three studies cited by Levy and colleagues in their reply, two are inpatient studies in adults (1,2) while the third (3) is an RCT in children of giving versus not giving written self management plans after ED attendance. The post hospital bronchodilator regimen was the same in the two groups. Children with written self management plans did better. Thus we do not have evidence on the relative merits of different bronchodilator regimens for post-hospital treatment.
Avoiding failure to recognise deterioration of asthma control is best addressed by giving good clear safety netting advice.
As for toxicity, salbutamol in the acute setting is a remarkably safe drug. In the past wheezing children were given oral salbutamol in a dose of 2mg (equivalent to 20 puffs from an MDI) three times daily. This is no longer done since the inhaled route is preferable and allows lower dosage but significant safety concerns did not arise. Large numbers of children are given repeated high dose salbutamol in hospital without evidence of harm.
Regular long term over-use of salbutamol is a marker of non compliance with prophylactic treatment and a risk factor for hospital admission and death. But there is a risk that in the minds of both health professionals and parents awareness of this may create unjustified concerns about the safety of using the high doses that are necessary in an exacerbation.
If we are looking for reasons for the unacceptably high mortality from asthma in children and young people in the UK, and for unnecessarily high admission and re-admission rates, we need also to consider that good patient education is crucial for effective asthma care. One feature of our relative underinvestment in health services is that waiting time for consultations is longer and consultation times for primary care professionals are shorter than in most countries of comparable economic status.
Duncan Keeley
Dr Duncan Keeley
General practitioner
Thame OX9 3JF
References
1. Bradding P, Rushby I, Scullion J and Morgan MD, As-required versus regular nebulized salbutamol for the treatment of acute severe asthma. Eur Respir J, 1999; 13: 290-4.
2. Chandra A, Shim C, Cohen HW, et al., Regular vs ad-lib albuterol for patients hospitalized with acute asthma. Chest, 2005; 128: 1115-20.
3. Ducharme FM, Zemek RL, Chalut D, McGillivray D, Noya FJD, Resendes S, et al. Written Action Plan in Pediatric Emergency Room Improves Asthma Prescribing, Adherence, and Control. American Journal of Respiratory and Critical Care Medicine. 2011;183(2):195-203.
Competing interests: No competing interests