RANDOMIZED TRIAL OF INTRAVENOUS SALBUTAMOL IN EARLY MANAGEMENT OF ACUTE SEVERE ASTHMA IN CHILDREN

Background The mainstay of treatment for acute asthma in children is n ebulised beta(2)-adrenergic agents such as salbutamol, given with cort icosteroids. However, penetration of the drug to the small airways is impeded by obstruction so intravenous salbutamol may be more effective . We assessed the use of intravenous salbutamol in the management of c hildren with acute severe asthma in a double-blind randomised study. M ethods Children who presented to the Emergency Department of Westmead Hospital, Sydney, Australia with asthma were assessed with a clinical assessment scale, and those with severe acute asthma were given nebuli sed salbutamol at a dose of 2.5 mg (age less than or equal to 2 years) or 5.0 mg (age >2 years), made up to 4 mL with saline. Children who d id not improve were eligible to enter phase one of the study. In this phase (0 h-2 h) treatment was by a standard protocol: nebulised salbut amol at the above dose; 4 L/min or 6 L/min continuous oxygen until oxy gen saturation reached 93% in room air for at least 30 min; a bolus of intravenous hydrocortisone 5 mg/kg given over 3 min; and then 15 mu g /kg intravenous salbutamol or saline, depending on randomised allocati on. In phase two (2 h-24 h) the children were given nebulised salbutam ol continuously then at 30 min, 1 h, 2 h, 3 h, and 4 h, according to n eed. All children were transferred to the ward once they were ready to start hourly nebulisation. All patients were followed up until discha rge. The primary endpoints were recovery time (no longer requiring inh aled salbutamol) and persistent moderate to severe asthma 2 h after ra ndomisation. Analyses were by intention-to-treat although no withdrawa ls occurred. Findings The recovery time (time to cessation of nebulise d salbutamol every 30 min) was 4 h in the 14 children allocated intrav enous salbutamol compared with 11.5 h for the 15 children in the contr ol group. 2 (14%) of the intravenous salbutamol group compared with 8 (53%) of the control group needed oxygen to maintain oxygen saturation at 93% room air. The intravenous salbutamol group were ready for disc harge from the emergency department 9.7 h earlier than the control gro up. No clinically significant side-effects were found in either group. Interpretation Addition of a 10 min infusion of salbutamol in the ear ly treatment of children with acute severe asthma has the potential to curtail the clinical progression of asthma, reduce demand placed on h ospital resources, and improve the quality of health care provided to the acutely sick child with asthma.