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Analysis of guideline recommendations for treatment of asthma exacerbations in children: a Pediatric Emergency Research Networks (PERN) study
  1. Simon Craig1,2,
  2. Madeline Collings1,
  3. Charmaine Gray3,4,
  4. Javier Benito5,6,
  5. Roberto Velasco7,8,
  6. Mark D Lyttle9,10,
  7. Damian Roland11,12,
  8. Suzanne Schuh13,14,
  9. Bashar Shihabuddin15,16,
  10. Maria Kwok17,18,
  11. Prashant Mahajan19,
  12. Mike Johnson20,
  13. Joseph Zorc21,22,
  14. Kajal Khanna23,
  15. Ricardo Fernandes24,25,
  16. Adriana Yock-Corrales26,
  17. Indumathy Santhanam27,28,
  18. Baljit Cheema29,
  19. Gene Yong-Kwang Ong30,31,
  20. Thiagarajan Jaiganesh32,
  21. Colin Powell33,
  22. Gillian Nixon1,34,
  23. Stuart Dalziel35,36,
  24. Franz E Babl1,37,38,39,
  25. Andis Graudins40,41
  1. 1 Department of Paediatrics, Monash University, Clayton, Victoria, Australia
  2. 2 Department of Paediatric Emergency, Monash Health, Clayton, Victoria, Australia
  3. 3 Adelaide Medical School, Discipline of Paediatrics, The University of Adelaide, Adelaide, South Australia, Australia
  4. 4 Department of Paediatric Emergency, Flinders Medical Centre, Bedford Park, South Australia, Australia
  5. 5 Department of Pediatric Emergency, Cruces University Hospital, Bilbao, Basque Country, Spain
  6. 6 University of the Basque Country, Bilabo, Basque Country, Spain
  7. 7 Pediatric Emergency Unit, Hospital Universitari Parc Taul, Sabadell, Spain
  8. 8 Paediatrics and Child Health, University College Cork, Cork, Ireland
  9. 9 Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
  10. 10 Research in Emergency Care Avon Collaborative Hub (REACH), University of the West of England, Bristol, UK
  11. 11 SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, UK
  12. 12 Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Department of Children’s Emergency, Leicester Royal Infirmary, Leicester, UK
  13. 13 Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
  14. 14 SickKids Research Institute, Toronto, Ontario, Canada
  15. 15 Division of Emergency Medicine, Nationwide Children's Hospital, Colombus, Ohio, USA
  16. 16 College of Medicine, The Ohio State University, Columbus, Ohio, USA
  17. 17 Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
  18. 18 Department of Pediatric Emergency, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
  19. 19 Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
  20. 20 Department of Pediatrics, Division of Pediatric Emergency Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA
  21. 21 Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  22. 22 Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  23. 23 Department of Emergency Medicine, School of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
  24. 24 Department of Pediatrics, Hospital de Santa Maria, Lisboa, Portugal
  25. 25 Clinical Pharmacology Unit, University of Lisbon, Lisboa, Portugal
  26. 26 Department of Emergency, Hospital Nacional de Ninos Dr Carlos Saenz Herrera, C.C.S.S, San Jose, Costa Rica
  27. 27 National Health Mission, Tamil Nadu, India
  28. 28 PREM Simulation Laboratory, Institute of Child Health, Madras Medical College, Chennai, India
  29. 29 Department of Paediatrics & Child Health, University of Cape Town Faculty of Health Sciences, Western Cape, South Africa
  30. 30 Children's Emergency Department, KK Women's and Children's Hospital, Singapore
  31. 31 Medical School, Duke University and the National University of Singapore, Singapore
  32. 32 Department of Emergency, Tawam Hospital, Al Ain, Abu Dhabi, UAE
  33. 33 Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
  34. 34 Department of Respiratory Medicine, Monash Children's Hospital, Clayton, Victoria, Australia
  35. 35 Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
  36. 36 Department of Children's Emergency, Starship Children's Health, Auckland, New Zealand
  37. 37 Department of Emergency, Royal Children’s Hospital, Melbourne, Victoria, Australia
  38. 38 Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
  39. 39 Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia
  40. 40 Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
  41. 41 Monash Emergency Service, Emergency Department, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia
  1. Correspondence to Dr Simon Craig, Department of Paediatrics, Monash University, Clayton, Victoria, Australia; simon.craig{at}monash.edu

Abstract

Rationale There is significant practice variation in acute paediatric asthma, particularly severe exacerbations. It is unknown whether this is due to differences in clinical guidelines.

Objectives To describe and compare the content and quality of clinical guidelines for the management of acute exacerbations of asthma in children between geographic regions.

Methods Observational study of guidelines for the management of acute paediatric asthma from institutions across a global collaboration of six regional paediatric emergency research networks.

Measurements and main results 158 guidelines were identified. Half provided recommendations for at least two age groups, and most guidelines provided treatment recommendations according to asthma severity.

There were consistent recommendations for the use of inhaled short-acting beta-agonists and systemic corticosteroids. Inhaled anticholinergic therapy was recommended in most guidelines for severe and critical asthma, but there were inconsistent recommendations for its use in mild and moderate exacerbations. Other inhaled therapies such as helium-oxygen mixture (Heliox) and nebulised magnesium were inconsistently recommended for severe and critical illness.

Parenteral bronchodilator therapy and epinephrine were mostly reserved for severe and critical asthma, with intravenous magnesium most recommended. There were regional differences in the use of other parenteral bronchodilators, particularly aminophylline.

Guideline quality assessment identified high ratings for clarity of presentation, scope and purpose, but low ratings for stakeholder involvement, rigour of development, applicability and editorial independence.

Conclusions Current guidelines for the management of acute paediatric asthma exacerbations have substantial deficits in important quality domains and provide limited and inconsistent guidance for severe exacerbations.

  • respiratory medicine
  • emergency care
  • paediatrics

Data availability statement

Data are available upon reasonable request. Data are available on reasonable request. De-identified data will be available for sharing from 1 January 2025. Any data access requests should be sent to SC (simon.craig@monash.edu) and should include a proposal from the individual or organisation regarding their plan for use of the data.The study team will review the request and consider the scientific merit of the proposed use of the data, and the legal, regulatory and ethical issues pertinent to the request. Presuming all constraints are addressed, the data will be shared using a secure file transfer platform.

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Data availability statement

Data are available upon reasonable request. Data are available on reasonable request. De-identified data will be available for sharing from 1 January 2025. Any data access requests should be sent to SC (simon.craig@monash.edu) and should include a proposal from the individual or organisation regarding their plan for use of the data.The study team will review the request and consider the scientific merit of the proposed use of the data, and the legal, regulatory and ethical issues pertinent to the request. Presuming all constraints are addressed, the data will be shared using a secure file transfer platform.

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Footnotes

  • Twitter @DrSimonCraig, @JavierBenitoF, @RoberVelasco80, @mdlyttle, @damian_roland, @adriyock

  • Contributors SC, FEB, CP, SD and AG identified the research question. SC was responsible for the study design and research protocol, with input from all authors. JB, RV, MC and SC obtained data supervised data extraction and analysis. SC was responsible for statistical analysis. SC drafted the initial manuscript. All authors contributed equally to writing, reviewing and editing the manuscript. All authors provided comments on the drafts and have read and approved the final version of the article. All authors had full access to all of the data (including statistical reports and tables) at the conclusion of the study and take responsibility for the integrity of the data and the accuracy of the data analysis. SC is the guarantor for the paper, accepts full responsibility for the work and/or the conduct of the study, had access to the data and controlled the decision to publish.

  • Funding This work is supported by the NHMRC Centre of Research Excellence in Paediatric Emergency Medicine (GNT1171228), Canberra, Australia. SC’s contribution was funded by the Thoracic Society of Australia and New Zealand and National Asthma Council Fellowship, 2020 and the Australasian College for Emergency Medicine Foundation Al Spilman Early Career Research Grant 2017. SDs time was in part funded by Cure Kids New Zealand. FEB’s time was funded by an NHMRC Investigator Leadership grant (GNT2017605) and the Royal Children’s Hospital Foundation, Parkville, Australia.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.