Scenario

A 5-year-old girl with known asthma presents to your emergency department with acute shortness of breath and wheeze. You diagnose a moderate acute exacerbation of asthma and wonder if there is a role for montelukast in her acute management?

Structured clinical question

In a child presenting with a moderate acute exacerbation of asthma [patient] does a short course of montelukast [intervention] reduce the severity of the asthma exacerbation [outcome]?

Search strategy and outcome

PubMed and Medline (1966 to September 2006) using the OVID interface were analysed for articles containing the key words ‘montelukast’, ‘leukotriene receptor antagonist’ and ‘asthma’. Limits included: human and English language only. Medline was searched using ‘montelukast’, ‘acute asthma’ and ‘child’.

A search of secondary sources revealed no relevant articles.

Of the 30 studies found, four were suitable (see table 2). One review (study 5) is also discussed in appendix 1.

Commentary

Acute exacerbations of asthma are responsible for a large proportion of hospital attendances in children. Their severity can be classified as mild, moderate, severe or life-threatening (using the SIGN/BTS criteria8). Regular use of a leukotriene receptor antagonist such as montelukast has been shown to be effective in children with mild intermittent asthma by improving lung function, decreasing exacerbations and improving symptoms.5 6 The evidence for montelukast initiated for acute exacerbations remains mixed. In the largest study, Robertson et al2 assessed the efficacy of parent-led therapy of 220 children (681 treated episodes of wheeze) using montelukast compared to placebo, and demonstrated both cost-effectiveness and a significant reduction in the burden of exacerbations, and a non-significant reduction in the number of visits to hospital and frequency of use of oral …