DENVER – If emergency workers give children with acute asthma exacerbations intravenous methylprednisolone before they reach the hospital, those children end up spending less time in the emergency department, and perhaps have shorter hospital stays if they are admitted, according to a study from the Baylor College of Medicine.
"This is something that’s been shown in adult populations to work quite well in mitigating the negative outcomes associated with asthma exacerbations," and now for the first time it’s been shown to help children, too, said the study’s lead author, Dr. David N.R. Hooke, at the annual meeting of the Pediatric Academic Societies.
The Houston Fire Department – which handles medical emergency calls in Houston – added intravenous methylprednisolone (Solu-Medrol) to its asthma exacerbation protocol in the spring of 2008, said Dr. Hooke, a Baylor fellow in pediatric emergency medicine.
Giving IV methylprednisolone in the field for acute exacerbations isn’t something done everywhere, Dr. Hooke said, but it makes sense given the adult outcomes and also because steroids in the hospital and outpatient setting are known to shorten exacerbations.
In general, "the Houston Fire Department is very open to putting together pediatric protocols for prehospital care. The push right now is toward getting these children treated as quickly as possible," he said.
Dr. Hooke and his colleagues compared outcomes for 32 children brought to the Texas Children’s Hospital, Houston, with acute asthma exacerbations during May 2007–April 2008, before the addition of IV methylprednisolone, to outcomes for 32 children brought there for the same problem during May 2008–July 2010, with the patients matched by triage acuity.
The children in the later group received 2 mg/kg of the medication 23 minutes, on average, before they arrived at hospital. Children in the earlier group received IV methylprednisolone as well, but waited an average of 84 minutes in the emergency department before getting it. Both groups received continuous albuterol by nebulizer throughout transport.
Receiving IV methylprednisolone sooner seemed to make a difference. The mean emergency department length of stay for the later group was 237 minutes, compared with 338 minutes for children treated earlier, a significant difference.
Similarly, the mean hospital length of stay was 2.2 days in the children treated after April 2008, compared with 3 days in the group treated earlier. That finding was not significant (P = .056), but did demonstrate a trend toward shorter hospital stays, Dr. Hooke said.
The study had several limitations. Because the children were matched by acuity, there was wide variation in age and gender between two groups; 22 (69%) of children in the post–protocol change group were boys, and the mean age in that group was 9.8 years. In the earlier group, 12 (38%) were boys, and the group’s mean age was 6.6.
Also, the study did not meet its target sample size, perhaps because emergency workers were slow to adopt the new protocol. "Larger sample sizes are necessary to determine the effect with greater confidence," Dr. Hooke and his colleagues concluded.
Finally, when methylprednisolone was added to the protocol, ipratropium was dropped. "There have been several research papers that have questioned the utility of ipratropium in patients younger than 12," and it’s expensive, Dr. Hooke noted.
Removing it from the protocol is a possible confounder, "but from my personal experience, I do not believe that the addition or removal of ipratropium made much difference," he said.
Even with the limitations, "the prehospital setting provides the opportunity to initiate timely treatment for asthma exacerbations," the researchers concluded.
Asthma isn’t the only target for prehospital care. "Other things can be done as well, such as getting acutely dehydrated children rehydrated either by mouth or by vein," something not often done in the field, Dr. Hooke said.
For clinicians interested in such measures, "the main thing is to form bridges with their [emergency medical services] companies and get these sorts of protocols in place," he said.
That could be problematic in some places. "A lot of cities don’t have a unified provider of services like Houston does. They have many different companies sort of doing what they want to do," making it harder for protocol changes to be widely adopted, he said.
But "if we can help children and reduce costs, it’s important, especially in the environment we practice in now," he said.
The study received no external funding. Dr. Hooke said he has no disclosures.