Variation in Treatment of Acute Childhood Wheeze in EDs
Thirty centres participated and 183/226 (81%) consultants completed the survey. Responses were obtained from a range of regions, department types and specialties (Table 1). A total of 29 (96.7%) departments had a CPG and 12 (40%) had a CP. All CPGs reflected national guidance with variations mainly in drug and dose selection. In all, 20 (66.7%) described specific admission locations for children receiving intravenous therapy. In 15 (75%), this included a paediatric high dependency unit and in 7 (35%), an inpatient ward. In 5 (25%), this included paediatric intensive care (PIC) with two mandating PIC if on intravenous salbutamol.
Most clinicians (113, 61.7%) adopt the same approach in all children 1 year and older. Overall, 70 (38.3%) modify clinical care depending on whether the diagnosis is asthma or VIW, with several stating they are less likely to prescribe steroids for VIW. Minor variations exist in intensity of inhaled bronchodilators and timing of intravenous therapy. Most clinicians use the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) criteria to assess severity, the most common being 'inability to complete sentences, too breathless to talk/feed' (180, 98.4%) and hypoxia (177, 96.7%); 106 (57.9%) class episodes as severe if 'more than one (but not necessarily all) are present'. A total of 156 (85.2%) had a peak expiratory flow rate (PEFR) meter, but only 22 (14.1%) always use this to assess severity. Those who 'sometimes' use PEFR meters do so in 'older children' or those with known PEFR (Table 2).
All clinicians use inhaled salbutamol. A total of 117 (63.9%) use nebulisers in the presence of hypoxia and metered dose inhalers (MDIs) in its absence, most commonly giving three doses initially followed by reassessment. In all, 173 (94.6%) use ipratropium bromide at least sometimes: 75 (43.4%) do so immediately and 67 (38.7%) if no response to the first salbutamol dose. Dosages of both vary in general increasing with age, though in some cases the same dose is given across all age ranges, most noticeably in salbutamol MDI (Table 3).
All use prednisolone 1–2 mg/kg as the oral steroid of choice; none use dexamethasone. A total of 181 (98.9%) use hydrocortisone as the intravenous steroid of choice. In all, 73 (39.8%) use intravenous steroids 'only if oral is not tolerated', 46 (25.1%) use intravenous 'when giving intravenous bronchodilators regardless of whether oral steroid has been given' and 27 (14.8%) use intravenous 'when giving intravenous bronchodilators if oral steroid has not been given'. None use inhaled steroids acutely.
In all, 170 (92.9%) escalate for deteriorating severe wheeze, 166 (90.7%) for life-threatening wheeze and 141 (77%) if there is no response to inhaled bronchodilators; 167 (91.8%) require more than one criterion and 172 (93.9%) use these on a case-by-case basis. Low numbers use set criteria such as time since starting or total accrued dose of inhaled therapy. In all, 99 (54.1%) use salbutamol as first-line intravenous therapy, 52 (28.4%) magnesium sulfate and 27 (14.8%) aminophylline; 87 (47.5%) give these sequentially depending on response and 30 (16.4%) give them concurrently. Overall, 146 (79.8%) continue inhaled bronchodilators while on intravenous therapy.
A total of 170 (92.9%) use intravenous salbutamol, though in a range of strategies and doses. For the purposes of this study, a continuous infusion was defined as a 'weight based rate (micrograms/kg/min) with no fixed endpoint'; a loading dose as a 'weight based rate (micrograms/kg/min) given for a set period of time' and a bolus as a 'weight based dose (micrograms/kg)'. Five general strategies are employed, the most common being 'bolus and continuous infusion'. For boluses, four doses and seven durations were described. There were 10 different continuous infusion rates with over 10-fold variation between the lowest and highest (Table 4).
Overall, 142 (77.6%) use aminophylline, with 127 (89.4%) giving 'bolus and infusion'; 132 (93%) give a bolus, of which 120 (91%) give 5 mg/kg, 5 (3.8%) give each of 6 or 7.5 mg/kg and one 10 mg/kg. In all, 120 (91%) give the bolus over 20–30 min. Nine continuous infusion rates were described, all at 1 mg/kg/h or less, with 1 mg/kg/h being the most common (68.6%).
In all, 173 (94.5%) use magnesium sulfate; all used a bolus with no subsequent infusion and 141 (81.5%) give 40–50 mg/kg over 20–30 min.
A total of 116 (62%) stated that more invasive therapy including intubation was outside their scope of practice. Of 67 (36.7%) who intubate, 62 (93%) use ketamine for induction of anaesthesia. Overall, 41 (24%) use non-invasive ventilation and 4 (2%) use heliox. Other therapies included adrenaline (4, 2.2%), high flow oxygen (4, 2.2%), calm environment (3, 1.6%), DNAse (2, 1.1%), physiotherapy (1, 0.5%), total histamine blockade (1, 0.5%), intravenous ketamine (1, 0.5%) or monteleukast (1, 0.5%).
Results
Thirty centres participated and 183/226 (81%) consultants completed the survey. Responses were obtained from a range of regions, department types and specialties (Table 1). A total of 29 (96.7%) departments had a CPG and 12 (40%) had a CP. All CPGs reflected national guidance with variations mainly in drug and dose selection. In all, 20 (66.7%) described specific admission locations for children receiving intravenous therapy. In 15 (75%), this included a paediatric high dependency unit and in 7 (35%), an inpatient ward. In 5 (25%), this included paediatric intensive care (PIC) with two mandating PIC if on intravenous salbutamol.
Assessment and General Approach
Most clinicians (113, 61.7%) adopt the same approach in all children 1 year and older. Overall, 70 (38.3%) modify clinical care depending on whether the diagnosis is asthma or VIW, with several stating they are less likely to prescribe steroids for VIW. Minor variations exist in intensity of inhaled bronchodilators and timing of intravenous therapy. Most clinicians use the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) criteria to assess severity, the most common being 'inability to complete sentences, too breathless to talk/feed' (180, 98.4%) and hypoxia (177, 96.7%); 106 (57.9%) class episodes as severe if 'more than one (but not necessarily all) are present'. A total of 156 (85.2%) had a peak expiratory flow rate (PEFR) meter, but only 22 (14.1%) always use this to assess severity. Those who 'sometimes' use PEFR meters do so in 'older children' or those with known PEFR (Table 2).
Inhaled Bronchodilators
All clinicians use inhaled salbutamol. A total of 117 (63.9%) use nebulisers in the presence of hypoxia and metered dose inhalers (MDIs) in its absence, most commonly giving three doses initially followed by reassessment. In all, 173 (94.6%) use ipratropium bromide at least sometimes: 75 (43.4%) do so immediately and 67 (38.7%) if no response to the first salbutamol dose. Dosages of both vary in general increasing with age, though in some cases the same dose is given across all age ranges, most noticeably in salbutamol MDI (Table 3).
Steroids
All use prednisolone 1–2 mg/kg as the oral steroid of choice; none use dexamethasone. A total of 181 (98.9%) use hydrocortisone as the intravenous steroid of choice. In all, 73 (39.8%) use intravenous steroids 'only if oral is not tolerated', 46 (25.1%) use intravenous 'when giving intravenous bronchodilators regardless of whether oral steroid has been given' and 27 (14.8%) use intravenous 'when giving intravenous bronchodilators if oral steroid has not been given'. None use inhaled steroids acutely.
Escalating to Intravenous Therapy
In all, 170 (92.9%) escalate for deteriorating severe wheeze, 166 (90.7%) for life-threatening wheeze and 141 (77%) if there is no response to inhaled bronchodilators; 167 (91.8%) require more than one criterion and 172 (93.9%) use these on a case-by-case basis. Low numbers use set criteria such as time since starting or total accrued dose of inhaled therapy. In all, 99 (54.1%) use salbutamol as first-line intravenous therapy, 52 (28.4%) magnesium sulfate and 27 (14.8%) aminophylline; 87 (47.5%) give these sequentially depending on response and 30 (16.4%) give them concurrently. Overall, 146 (79.8%) continue inhaled bronchodilators while on intravenous therapy.
Intravenous Bronchodilators
A total of 170 (92.9%) use intravenous salbutamol, though in a range of strategies and doses. For the purposes of this study, a continuous infusion was defined as a 'weight based rate (micrograms/kg/min) with no fixed endpoint'; a loading dose as a 'weight based rate (micrograms/kg/min) given for a set period of time' and a bolus as a 'weight based dose (micrograms/kg)'. Five general strategies are employed, the most common being 'bolus and continuous infusion'. For boluses, four doses and seven durations were described. There were 10 different continuous infusion rates with over 10-fold variation between the lowest and highest (Table 4).
Overall, 142 (77.6%) use aminophylline, with 127 (89.4%) giving 'bolus and infusion'; 132 (93%) give a bolus, of which 120 (91%) give 5 mg/kg, 5 (3.8%) give each of 6 or 7.5 mg/kg and one 10 mg/kg. In all, 120 (91%) give the bolus over 20–30 min. Nine continuous infusion rates were described, all at 1 mg/kg/h or less, with 1 mg/kg/h being the most common (68.6%).
In all, 173 (94.5%) use magnesium sulfate; all used a bolus with no subsequent infusion and 141 (81.5%) give 40–50 mg/kg over 20–30 min.
Other Therapies
A total of 116 (62%) stated that more invasive therapy including intubation was outside their scope of practice. Of 67 (36.7%) who intubate, 62 (93%) use ketamine for induction of anaesthesia. Overall, 41 (24%) use non-invasive ventilation and 4 (2%) use heliox. Other therapies included adrenaline (4, 2.2%), high flow oxygen (4, 2.2%), calm environment (3, 1.6%), DNAse (2, 1.1%), physiotherapy (1, 0.5%), total histamine blockade (1, 0.5%), intravenous ketamine (1, 0.5%) or monteleukast (1, 0.5%).