Question 1: Prednisoloneor dexamethasone for acute exacerbations of asthma: do they have similar ef ficacy in the management of exacerbations of childhood asthma?

摘要

SCENARIO You are asked to see a 6-year-old child who has come into hospital with an acute exacerbation of asthma. She is able to talk in full sentences, however, her respirations are 40/min with audible wheeze, and you prescribe 10 puffs of salbutamol as initial management. The British Thoracic Society (BTS) guidelines recommend early use of steroids to decrease admission rate and length of stay,1 and you feel steroids would be of value for this child. However the mother of your patient explains her daughter hates taking any medications. You have read an article about dexamethasone being a shorter treatment course with better compliance and wonder if it has similar efficacy to prednisolone.QUESTION In children who have an acute exacerbation of asthma requiring steroids (population), does dexamethasone (intervention) have similar efficacy to prednisolone (comparison) in achieving decreased airway inflammation, decreased admission rates and length of hospital stay (outcome) ?SEARCH STRATEGY AND OUTCOME Medline (1996 to September week 2 2012) and Embase (1996 to 20 September 2012) were searched via Ovid on 21 September 2012 using the search terms ((dexamethasone AND prednisolone) or (dexamethasone AND prednisone)) AND ((acute asthma) OR (asthma exacerbation)). A total of 82 abstracts were reviewed, and six relevant studies were found: five papers were identified after review of abstracts, and a further paper from referenced citations. These are summarised in table 1.COMMENTARY Asthma is characterised by reversible airways obstruction, and exacerbations can be triggered by a variety of stimuli. Corticosteroids have been found to decrease airway inflammation for allergic and non-allergic causes.2 An umbrella review including Cochrane reviews highlighted reduced hospital admissions after adults with acute asthma were treated with early systemic corticosteroids.3 Corticosteroids were first shown to be effective in adults in 1986, and the first study supporting paedi-atric use was in 1990.4Prednisolone is the most commonly prescribed corticosteroid for asthma exacerbations, and stated to be the preferred choice Where does evidence based medicine go without evidence? I have recently been working with lots of folk who manage children with disability and long-term conditions, a massive group of heterogenously named conditions with sometimes similar and sometimes different problems. The teams working with them are passionate and committed and frequently want to use research.Then they go looking for it and frequently find nothing.Now—the experience of not finding evidence to help your question is not unique to disabilities—there are plenty of uncertainties in children's cancer, neonatology and diabetes. How can you move on without evidence in an evidence based way?We can take this forward in two ways. First, acknowledging the lack of really good evidence, we should use indirect, analogous and 'lower level' evidence.1 Responding to the clinical problem will be combining what data we do and do not have with discussions with the parents and child/young person.Second, we might use this to generate a clinical study question and seek folks to answer it. Evidence-based medicine is certainly not clinical research, but many really important clinical trials develop from the gaps identified by this sort of approach.Do not be upset when you find nothing—it's not that uncommon2 to go searching and find very little—but remember that evidence based medicine is possible, even without obvious evidence.