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I am writing in response to Dr South’s recent editorial which highlighted how second line treatment for severe acute childhood asthma is still the subject of debate.1 I conducted a survey of consultant paediatricans who were clinical leads in asthma at 582 NHS establishments across the UK (details from official published lists) in which they were asked to indicate their department’s preferred choice for second line treatment of acute severe asthma not responding adequately to first line treatment with high dose nebulised bronchodilators and corticosteroids. I also invited them to make any additional comments or remarks.
A total of 252 responses were received (43.3% response rate), of which 25 stated that their NHS establishment either did not treat children or did not treat acute asthma. The 227 remaining responses and feedback comments for each treatment choice are summarised in box 1.
Box 1 Summary of survey results
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IV aminophylline: 159 replies (70.0%):
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– 14 (9%) departments plan to change to IV salbutamol in the future;
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– believe evidence for IV salbutamol not good despite new guidelines;
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– tried to change policy to IV salbutamol but colleagues not keen;
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– practice may be out of date;
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– familiar with aminophylline—safe and effective over many decades;
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– nurses find volumes required to make up IV salbutamol problematic;
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– nurses insist IV salbutamol only administered on PICU due to hypokalaemia.
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IV salbutamol: 34 replies (15.0%):
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– 11 (32%) departments based in London;
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– use IV salbutamol to standardise with other local centres;
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– considering changing back to aminophylline as felt it was more effective.
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IV aminophylline or IV salbutamol: 28 replies (12.3%):
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– choice based on individual doctors and details of individual cases;
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– 5 (18%) departments moving towards IV salbutamol as main choice.
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IV terbutaline: 3 replies (1.3%)
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IV magnesium: 1 reply (0.4%)
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No choice: 2 replies (0.9%):
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– feel unable to state what actually happens in reality in department
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The results highlight how clinical practice can sharply contrast with clinical guidelines. It is arguable how the results should be interpreted. Should we standardise with the majority of the UK and use IV aminophylline or should we follow guidelines and use IV salbutamol, despite the evidence being unclear and it only being used by a minority of departments across the UK? It would be interesting to repeat this exercise in 10 years’ time to see what direction departments across the UK decide to follow.
Reference
Author’s reply
Dr Vijayafeva’s survey of the choice of second line drug treatment for severe acute childhood asthma by UK consultant paediatricians has some very interesting findings. Most of the paediatricians (70.4%) gave IV aminophylline as their preferred choice despite the fact that national guidelines recommend IV salbutamol. Could this be practice change inertia, or is it the result of years of experience with the long established agent aminophylline and the lack of conviction that IV salbutamol is better?
That there is considerable practice variation is not a surprise and may be a healthy situation, given that the evidence for superiority between IV salbutamol and IV aminophylline remains somewhat inconclusive. I was interested to note that some prescribers had switched to salbutamol in accordance with the guidelines but were now considering changing back to aminophylline as they felt it was more effective.
My conclusion from reading the literature, as outlined in my editorial in Thorax,1 is that the limited evidence suggests that aminophylline has advantages for efficacy in severe cases but at the cost of additional minor adverse effects. The higher rate of use of aminophylline by UK paediatricians sits comfortably with this. It may be the guideline, rather than the prescribing practice, which needs to be updated.