Re: Conflicting asthma guidelines cause confusion in primary care
Unfortunately Dr Paton and colleague’s response to our letter did not provide evidence supporting the regular use of high or low dose salbutamol following treatment of asthma attacks, nor do they acknowledge the potential risk to patients and carers of failing to recognise deterioration of asthma control, or potential toxity. Since the 1990s, with the learnings from the asthma mortality epidemics and the RCTs that followed, most guidelines (apart from the SIGN/BTS Guideline as referred to in our original letter) have not recommended regular (rather than as-needed) SABA for asthma in any clinical context except in the first hour of ED treatment. In the context of asthma exacerbations, the evidence we are aware of includes three RCTs. Two involved adult patients hospitalised for acute asthma, (1,2) where as-needed SABA in hospital was associated in one study (1) with better outcomes (shorter length of stay, and fewer side-effects), and in both studies with lower SABA doses than with regular SABA. The third is a study in children treated in the A&E (ED) for acute asthma who were provided with written asthma action plans stipulating 'as needed' use of salbutamol, which resulted in better asthma control at 28 days, and only one acute care visit in the follow-up period. (3)
Sadly, in the UK, very few children are reviewed after treatment for asthma attacks (4) and by falsely reassuring parents that continued high dose salbutamol through the ‘weaning plan’ this will in our view delay identification of risk of deterioration (or failure to improve) with the added risk of avoidable unscheduled health care which increases workload and cost.
In the Product Information for salbutamol, the maximum recommended dose for children is 8 puffs in 24 hours. Without evidence, it is difficult to see how a recommendation to parents to give nearly 8 times this dose on the first day post-discharge, and to continue to exceed recommended maximum daily doses for several more days, can be supported. The current justification for the weaning plan approach, according to Dr Paton, is to facilitate early discharge from hospital care following initial treatment of an asthma attack. There is an urgent need to establish whether rapid discharge is safe while a child is still requiring 4 hourly high dose bronchodilator therapy. Currently we believe that the admittedly limited trial evidence suggests that it is safer to employ as needed reliever treatment after discharge, with clear guidance in a written action plan on the bail-out point based on continued symptoms and the need for frequent (>4hourly) high dose SABA.
Clearly, research is needed to establish the safety, cost effectiveness and clinical outcome of the use of weaning plans involving regular administration of SABA.
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.
4. Levy ML, Ward A, Nelson S. Management of children and young people (CYP) with asthma: a clinical audit report. npj Primary Care Respiratory Medicine. 2018;28(1):16.
Dr Mark L Levy FRCGP, London, United Kingdom, Clinical Lead UK National Review of Asthma Deaths (2011-2014)
Professor Andrew Bush, Professor of Paediatric Respirology, National Heart and Lung Institute, London, United Kingdom
Dr Louise Fleming, Clinical Senior Lecturer, National Heart and Lung Institute, Imperial College London Consultant Respiratory Paediatrician, Royal Brompton Hospital, United Kingdom.
Professor John O Warner MD FRCPCH FMedSci, Professor of Paediatrics Imperial College London, United Kingdom
Allan Becker MD, FRCPC, FCAHS, Professor and Head, Section of Allergy and Clinical Immunology, Department of Pediatrics and Child Health, University of Manitoba, Canada
Professor Helen Reddel, MBBS PhD, Woolcock Institute of Medical Research, Sydney, Australia
Dr Richard Iles, Consultant in Respiratory Paediatrics, Evelina London Childrens Hospital, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, United Kingdom
Soren Pedersen MD, DMsc., Professor of Pediatric Respiratory diseases at The University of Southern Denmark, Denmark
Competing interests:
No competing interests
21 November 2018
Mark L Levy
GP Locum
Professor Andrew Bush, Professor of Paediatric Respirology, National Heart and Lung Institute, London, United Kingdom ; Dr Louise Fleming, Clinical Senior Lecturer, National Heart and Lung Institute, Imperial College London Consultant Respiratory Paediatrician, Royal Brompton Hospital, United Kingdom. ; Professor John O Warner MD FRCPCH FMedSci, Professor of Paediatrics Imperial College London, United Kingdom ; Allan Becker MD, FRCPC, FCAHS, Professor and Head, Section of Allergy and Clinical Immunology, Department of Pediatrics and Child Health, University of Manitoba, Canada ; Professor Helen Reddel, MBBS PhD, Woolcock Institute of Medical Research, Sydney, Australia ; Dr Richard Iles, Consultant in Respiratory Paediatrics, Evelina London Childrens Hospital, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, United Kingdom ; Soren Pedersen MD, DMsc., Professor of Pediatric Respiratory diseases at The University of Southern Denmark, Denmark
Clinical Lead National Review of Asthma Deaths (2011-2014)
Rapid Response:
Re: Conflicting asthma guidelines cause confusion in primary care
Unfortunately Dr Paton and colleague’s response to our letter did not provide evidence supporting the regular use of high or low dose salbutamol following treatment of asthma attacks, nor do they acknowledge the potential risk to patients and carers of failing to recognise deterioration of asthma control, or potential toxity. Since the 1990s, with the learnings from the asthma mortality epidemics and the RCTs that followed, most guidelines (apart from the SIGN/BTS Guideline as referred to in our original letter) have not recommended regular (rather than as-needed) SABA for asthma in any clinical context except in the first hour of ED treatment. In the context of asthma exacerbations, the evidence we are aware of includes three RCTs. Two involved adult patients hospitalised for acute asthma, (1,2) where as-needed SABA in hospital was associated in one study (1) with better outcomes (shorter length of stay, and fewer side-effects), and in both studies with lower SABA doses than with regular SABA. The third is a study in children treated in the A&E (ED) for acute asthma who were provided with written asthma action plans stipulating 'as needed' use of salbutamol, which resulted in better asthma control at 28 days, and only one acute care visit in the follow-up period. (3)
Sadly, in the UK, very few children are reviewed after treatment for asthma attacks (4) and by falsely reassuring parents that continued high dose salbutamol through the ‘weaning plan’ this will in our view delay identification of risk of deterioration (or failure to improve) with the added risk of avoidable unscheduled health care which increases workload and cost.
In the Product Information for salbutamol, the maximum recommended dose for children is 8 puffs in 24 hours. Without evidence, it is difficult to see how a recommendation to parents to give nearly 8 times this dose on the first day post-discharge, and to continue to exceed recommended maximum daily doses for several more days, can be supported. The current justification for the weaning plan approach, according to Dr Paton, is to facilitate early discharge from hospital care following initial treatment of an asthma attack. There is an urgent need to establish whether rapid discharge is safe while a child is still requiring 4 hourly high dose bronchodilator therapy. Currently we believe that the admittedly limited trial evidence suggests that it is safer to employ as needed reliever treatment after discharge, with clear guidance in a written action plan on the bail-out point based on continued symptoms and the need for frequent (>4hourly) high dose SABA.
Clearly, research is needed to establish the safety, cost effectiveness and clinical outcome of the use of weaning plans involving regular administration of SABA.
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.
4. Levy ML, Ward A, Nelson S. Management of children and young people (CYP) with asthma: a clinical audit report. npj Primary Care Respiratory Medicine. 2018;28(1):16.
Dr Mark L Levy FRCGP, London, United Kingdom, Clinical Lead UK National Review of Asthma Deaths (2011-2014)
Professor Andrew Bush, Professor of Paediatric Respirology, National Heart and Lung Institute, London, United Kingdom
Dr Louise Fleming, Clinical Senior Lecturer, National Heart and Lung Institute, Imperial College London Consultant Respiratory Paediatrician, Royal Brompton Hospital, United Kingdom.
Professor John O Warner MD FRCPCH FMedSci, Professor of Paediatrics Imperial College London, United Kingdom
Allan Becker MD, FRCPC, FCAHS, Professor and Head, Section of Allergy and Clinical Immunology, Department of Pediatrics and Child Health, University of Manitoba, Canada
Professor Helen Reddel, MBBS PhD, Woolcock Institute of Medical Research, Sydney, Australia
Dr Richard Iles, Consultant in Respiratory Paediatrics, Evelina London Childrens Hospital, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, United Kingdom
Soren Pedersen MD, DMsc., Professor of Pediatric Respiratory diseases at The University of Southern Denmark, Denmark
Competing interests: No competing interests