Clinical factors associated with the use of dexamethasone for asthma in the pediatric emergency department

Abstract

Background

Dexamethasone is efficacious for the treatment of pediatric asthma exacerbations but is not specifically recommended by current national guidelines.

Objectives

To describe the factors associated with prescribed dexamethasone in a pediatric emergency department (PED) and upon patient discharge.

Methods

Retrospective chart review of patients aged 2 to 18 years discharged home from a PED with a diagnostic code for asthma (J45x). Descriptive statistics are reported and binary logistic regression with generalized estimating equations was used to examine the demographic and clinical factors associated with dexamethasone use in the PED and upon discharge.

Results

594 children contributed 690 visits for asthma. Two-thirds of patients received prednisone in the PED (n = 430; 62%). Among 260 children who received dexamethasone, 76% (n = 198) were prescribed a second dose for post-discharge administration. Multivariable models showed that patients triaged as most urgent had a 50% reduction in the odds of receiving dexamethasone in the PED (OR = 0.5; 95% CI = 0.28–0.87). Patients seen by a pediatrician (OR 4.2; 95%CI 2.1–8.3) and those triaged as urgent (OR 2.9; 95% CI = 1.8–7.8) were more likely to receive a single dose of dexamethasone.

Conclusions

Dexamethasone is less commonly used in the PED for asthmatic patients triaged as most urgent. Triage acuity and level of training were associated with single-dose treatment of asthma in those receiving dexamethasone. Further studies are needed to clarify the use of dexamethasone across the spectrum of asthma severity.

Keywords:

• Asthma exacerbation
• dexamethasone
• prednisone
• pediatric emergency department

Acknowledgements

All phases of this study were supported by Blue Cross Blue Shield of Michigan Foundation (002657.PIRAP) and the Children’s Hospital of Michigan Foundation (R2-2018–01). The funders had no role in the study design; the collection, analysis, and interpretation of the data; or the drafting of the manuscript.

Declarations of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Contributor statements

Dr. DeLaroche conceptualized and designed the study, designed the data collection instrument, interpreted the data, drafted the initial manuscript, and reviewed and revised the manuscript. Mr. Mowbray carried out the analyses and reviewed and revised the manuscript. Ms. Parker collected data, coordinated and supervised data collection, and reviewed and revised the manuscript. Dr. Ravichandran collected data, coordinated and supervised data collection, and reviewed and revised the manuscript. Mr. Jones supervised the analyses and reviewed and revised the manuscript.

Article summary

Why is this topic important?

Pediatric patients are commonly brought to the emergency department for asthma exacerbations, and systemic corticosteroids are recommended for acute management. Dexamethasone is equivalent to prednisone with the advantages of easier administration and improved patient compliance, but is not specifically recommended by national guidelines.

What does this study attempt to show?

The objective of this study is to describe the patient and clinical factors associated with the use of dexamethasone in the pediatric emergency department for children experiencing an acute asthma exacerbation.

What are the key findings?

One-third of children received dexamethasone in the PED and 76% were prescribed a second dose for post-discharge administration. Patients triaged as most urgent (ESI 1 or 2) and those with a lower pulse oximetry value were less likely to receive dexamethasone in the PED. Patients evaluated by a pediatrician and those triaged as urgent (ESI 3) were more likely to be treated with a single dose of dexamethasone.

How is patient care impacted?

Few demographic and clinical variables were associated with use of dexamethasone in the PED or upon discharge. Further studies are needed to clarify the use of dexamethasone across the spectrum of asthma severity.

Additional information

Funding

All phases of this study were supported by Blue Cross Blue Shield of Michigan Foundation (002657.PIRAP) and the Children’s Hospital of Michigan Foundation (R2-2018–01). The funders had no role in the study design; the collection, analysis, and interpretation of the data; or the drafting of the manuscript.