Asthma adjuncts
Kitchen sink #1 or kitchen sink #2? We know inhaled short acting bronchodilators and steroids are the mainstay, but after that, when the pediatric asthma patient is in critical condition, what should we be reaching for? An expert panel was recently formed to create guidelines for pediatric critical asthma. This network meta-analysis (NMA) is a follow up to their recommendations, as they didn't create a ranking of adjuncts in the initial report.
Why an NMA? A network meta-analysis is used when there are RCTs comparing option A vs. placebo, and option B vs placebo, and even option C vs. placebo, but very little data exists on A vs. B vs. C, head to head. Such is the case for IV magnesium, IV short-acting beta agonists (terbutaline, salbutamol), and IV methylxanthines (aminophylline, theophylline) in severe acute asthma exacerbations.
What did they do? They reviewed 12 RCTs with a total of 852 patients and performed a whole lotta statistical analysis in this NMA to find out which one is the best of the rest. Their primary outcomes were PICU admission, PICU LOS, intubation, and hospital LOS.
What did they find? Magnesium rules. In nearly every outcome, magnesium performed the best. Mag decreased PICU LOS (by 0.6-4 days), decreased intubation, decreased PICU admission (odds ratio 0.21), and decreased hospital LOS (by 0.5-3 days). Notably, they discuss how LOS is dependent on a lot of factors they did not control for, so these pretty big numbers should be taken with a grain of salt. IV SABAs were 2nd, and IV methylxanthines were 3rd.
Bottom Line: when your next pediatric asthma patient needs a little something more than steroids and nebulizers, reach for IV magnesium first.
Why an NMA? A network meta-analysis is used when there are RCTs comparing option A vs. placebo, and option B vs placebo, and even option C vs. placebo, but very little data exists on A vs. B vs. C, head to head. Such is the case for IV magnesium, IV short-acting beta agonists (terbutaline, salbutamol), and IV methylxanthines (aminophylline, theophylline) in severe acute asthma exacerbations.
What did they do? They reviewed 12 RCTs with a total of 852 patients and performed a whole lotta statistical analysis in this NMA to find out which one is the best of the rest. Their primary outcomes were PICU admission, PICU LOS, intubation, and hospital LOS.
What did they find? Magnesium rules. In nearly every outcome, magnesium performed the best. Mag decreased PICU LOS (by 0.6-4 days), decreased intubation, decreased PICU admission (odds ratio 0.21), and decreased hospital LOS (by 0.5-3 days). Notably, they discuss how LOS is dependent on a lot of factors they did not control for, so these pretty big numbers should be taken with a grain of salt. IV SABAs were 2nd, and IV methylxanthines were 3rd.
Bottom Line: when your next pediatric asthma patient needs a little something more than steroids and nebulizers, reach for IV magnesium first.
