Management of Asthma in a Pediatric Emergency Department

• Published in: Canadian journal of respiratory therapy : CJRT = Revue canadienne de la thérapie respiratoire : RCTR Vol. 44; no. 5; p. 22
• Main Authors: Touzin, Karine, Queyrens, Anne, Bussières, Jean-François, Languérand, Geneviève, Bailey, Benoît, Laberge, Nicole
• Format: Journal Article
• Language: English
• Published: Ottawa The Canadian Society of Respiratory Therapists 01.12.2008
• Subjects: Airway management; Asthma; Children & youth; Emergency medical care; Studies; Canada
• ISSN: 1205-9838; 2368-6820

We observed that use of the ED asthma clinical pathway did not influence the average delay in patient management by physicians (68.73 ± 58.27 min with pathway vs. 66.27 ± 56.14 min without, p=0.846), the mean ED length of stay or the average dose of β-2 agonists or dexamethasone administered to the patients, since we did not find any significant difference between the two groups studied. On the other hand, its use reduced in a non-significant way the delay in patient management by respiratory therapists (73.46 ± 54.93 min with pathway vs. 95.68 ± 58.17 min without, p=0.079) and the average delay in the administration of the initial dose of ß-2 agonists (75.54 ± 55.48 min with pathway vs. 97.27 ± 58.44 min without, p=0.088). The average delay in administering the initial dose of corticosteroid was significantly reduced when using the pathway (74.94 ± 51.47 min with pathway vs. 108.08 ± 81.06 min without, p=0.038). The corticosteroids that we found to be used most frequently in the ED for the treatment of asthma were dexamethasone (78.0% with the pathway vs. 82.9% without), prednisone (19.5% with the pathway vs. 19.5% without), fluticasone (7.3% with the pathway vs. 36.6% without) and budesonide (9.8% solely in the non-pathway patient group). There are few studies on the impact of an ED asthma clinical pathway on delays in patient management.6-9 Opinions diverge in the studies published on the subject as to the impact of the use of an ED asthma pathway on length of treatment, delay in patient management and patient treatment costs. In fact, some studies such as the one published by Kwan-Gett et al. conclude that using an asthma pathway does not reduce patient length of stay or associated treatment costs after having evaluated the impact of a clinical pathway in a pediatric hospital.10 Furthermore, we found some studies that reported both clinical and economic advantages when treating patients after using an ED asthma clinical pathway.11-14 These studies recognized that using a pathway, preferably with a pre-written tool, may help to increase the practitioners' compliance with guidelines and reduce the variance.15-17 The low rates of corticosteroid dose compliance in the pathway patient sample confirm that recommended doses and frequencies need to be updated for use with the asthma pathway. As a matter of fact, the latest consensus favors using dexamethasone at 0.6 mg/kg18-19 rather than 0.2 mg/kg as is now recommended in the ED asthma clinical pathway. The disparity between doses recommended in the ED asthma pathway and the latest asthma consensus guidelines shows that a revised pathway based on pediatric guidelines and recommendations set forth in the revised 2005 version of the Canadian Asthma Consensus Report may help to improve the benefits related to using the ED asthma clinical pathway.