medwireNews: Children discharged after being admitted to hospital with an acute attack of wheeze can be effectively managed with salbutamol on an as needed basis, resulting in lower doses than with a predefined weaning regimen, says a team of UK researchers.
There is currently “no clear discharge advice for salbutamol use in national guidelines,” other than the recommendation to discharge children once they are stable on regular 3- to 4-hourly bronchodilators, explain Gary Connett (University Hospital Southampton NHS Foundation Trust, UK) and colleagues in Archives of Disease in Childhood.
This can result in hospitals recommending continued use of regular bronchodilators on leaving hospital, with dose reductions according to predetermined fixed-dose regimens, they stress, adding that “there is no evidence to support this practice.”
The researchers therefore assessed outcomes with a new discharge plan that was developed by a healthcare team in collaboration with eight families of children treated for acute wheeze. It included a color-coded flowchart for 4-hourly symptom assessments by parents who were educated about managing wheeze attacks and the use of incremental salbutamol doses within safety limits, starting at two puffs up to a maximum of 10 if symptoms persist.
Age-specific instructions for metered dose inhaler (MDI) and spacer use were provided, along with links for video demonstrations of proper inhaler techniques.
Based on the data obtained from 103 families, taking salbutamol only when needed reduced its use by a mean of 73% on day 1, 69% on day 2, and 50% on day 3, compared with the expected use based on a fixed dose 4-hourly weaning regimen of using 10 puffs on day 1, five on day 2, and two on day 3, report the investigators.
After 3 days, only 13 children still required salbutamol, the researchers point out, and while eight visited their general practitioner over the following 2 weeks, this was not due to concerns over wheeze.
Connett and team also observed a trend in reduced hospital revisits with this approach, at 8.3 per 1000 children, within 1 week compared with the previous year's figure of 12.5 per 1000 children, with an odds ratio for re-admission of 0.66 when salbutamol is taken only when required.
“Our reattendance rates to the emergency department varied between 0% and 4.7% monthly and are comparable to those reported in a study of nurse-led interventions to reduce the use of hospital services after acute asthma admissions,” the researchers observe.
They say that parents and care providers of the children also preferred this practice, finding it easy to follow and confirmed that it had resulted in less use of salbutamol.
This approach also has additional “environmental benefits,” says the team, owing to the reduced use of MDIs that account for approximately 13% of the NHS’s carbon footprint.
The investigators believe that their data “provide good evidence to support a widespread change in practice in all UK centers to as required dosing regimes during the recovery phase of acute wheeze after hospital discharge.”
They add: “This approach is consistent with safe practice and patient preferences.”
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