Practical considerations of nebulized corticosteroid in children with acute asthmatic exacerbation: A consensus
Chalerat Direkwattanachai,1 Chalermthai Aksilp,2 Pantipa Chatchatee,3 Orathai Jirapongsananuruk,4 Haruthai Kamalaporn,1 Wasu Kamchaisatian,1 Sorasak Lochindarat,2 Lina Ngamtrakulpanit,5 Orapan Poachanukoon,6 Muthita Trakultivakorn,7 Jamaree Teeratakulpisarn,8 Kanokporn Udomittipong,4 Mukda Vangveeravong,2 Jitladda Deerojanawong3
1 Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
2 Department of Medical Services, Queen Sirikit National Institute of Child Health, Ministry of Public Health, Bangkok, Thailand
3 Pediatric Allergy & Clinical Immunology Research Unit, Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
4 Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
5 Bangkok Allergy and Asthma Center Bangkok Hospital, Bangkok, Thailand
6 Department of Pediatrics, Thammasat University Hospital, Pathum Thani, Thailand
7 Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
8 Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kean, Thailand
Abstract
Background: Acute asthmatic exacerbation in children causes economic burdens both directly and indirectly. The GINA guideline does mention the use of inhaled or oral corticosteroids in the treatment of asthmatic exacerbation, it provides little practical guidance on the use of nebulized corticosteroid.
Objective: To review and recommend the practical considerations in the use of nebulized corticosteroid in children with acute asthmatic exacerbation.
Methods: This consensus was developed by a group of expert pediatricians in respiratory and allergy fields in Thailand. The recommendations were made based on a review of published studies and clinical opinions. The eligible studies were confined to those published in English, and randomized controlled trials and meta-analyses involving nebulized corticosteroids in asthmatic exacerbation in children aged between 1-18 years.
Results: There were 13 randomized controlled-trial studies published from 1998 to 2017. Nine of the 13 studies compared nebulized with systemic corticosteroid conducted in moderate to severe exacerbation, while the remaining four compared nebulized corticosteroid with placebo conducted in mild to severe exacerbation. The admission rate was significantly lower in severe exacerbation (one study) and pooled four mild to severe exacerbation studies comparing with placebo (p 0.022). Other clinical parameters were significantly improved with nebulized corticosteroid such as clinical scores, systemic corticosteroid/bronchodilator use, or shorter ER stays. Only one study used fluticasone, while the other 12 studies conducted by budesonide (92.31%).
Conclusion: Nebulized corticosteroid may offer an effective therapeutic option for the management of acute exacerbation of asthma in all severities. Nebulized budesonide is the preferred corticosteroid.
Key words: budesonide, admission, bronchodilator, randomized-controlled trial, meta-analysis,