Ideal Steroids for Asthma Treatment in the PICU
Ideal Steroids for Asthma Treatment in the PICU
Determine if differences in (1) pediatric intensive care unit length of stay, (2) continuous
 nebulized albuterol duration, and (3) a composite outcome of advanced asthma therapy
 incidence including use of non-invasive ventilation (NIV), terbutaline, inhaled helium and
 mechanical ventilation between cohorts of children admitted with status asthmaticus to the
 PICU treated with either IV dexamethasone (DM) or methylprednisolone (MP).
As the pathophysiology of an acute asthma exacerbation is dysregulated inflammatory pathways,
 standard treatment includes the prompt initiation of intravenous systemic corticosteroids.
 Corticosteroids reduce the production of many mediators involved in the inflammatory process
 and inhibit macrophages, monocytes, T-lymphocytes, eosinophils, and basophils, which are
 activated during this process. Furthermore, corticosteroids improve the efficacy of beta-2
 agonists, such as albuterol, a nebulized medication used for bronchodilation in acute asthma
 exacerbations. There remains an ongoing dialogue among the expert medical community regarding
 the superiority of specific IV corticosteroid, dosing, route and delivery. This debate
 continues secondary to a lack of definitive comparative data in the literature. While the
 benefits of receiving systemic corticosteroids has been demonstrated in multiple studies, to
 date, no head-to-head trials have been conducted comparing IV systemic corticosteroids in the
 PICU setting (DM vs. MP).

 While several systemic corticosteroids are FDA approved for the treatment of asthma
 exacerbation including prednisone, prednisolone, MP and DM, the standard practice in
 PICU-level care is IV MP every 6 hours until enteral medications can be safely tolerated.
 Recent data from emergency room literature would suggest there is equipoise in use of
 dexamethasone as an alternative for methylprednisolone due to its increased glucocorticoid
 (anti-inflammatory) potency. Steroid agents are chosen at the discretion of clinical
 providers based upon a child's capacity to tolerate enteral medications and the specific
 clinical setting (outpatient vs. general inpatient vs. critical inpatient).

 The investigators have performed a retrospective study over a 2-year period to assess if
 differences in clinical outcomes or adverse events exist in cohorts defined by DM exposure in
 the ER. Their data revealed no differences, but most children were switched to MP during
 their PICU stay making data analyses severely confounded by exposure to the defining
 characteristics of the comparative cohort. The investigators seek to first prospectively
 consent individuals to receive DM during their PICU asthma treatment and compare outcomes to
 PICU asthmatics concurrently admitted to the PICU receiving local standard care (MP). JHACH
 admits approximately 150 asthmatics per year in the PICU and the investigators hope to enroll
 up to 50 subjects into a DM only arm. The comparative standard care arm will be assessed at
 the end of the study period. Primary outcomes include (1) PICU Length of Stay, (2) Continuous
 nebulized albuterol duration, and (3) a composite outcome including use of non-invasive
 ventilation (NIV), terbutaline, inhaled helium, inhaled anesthetic gas, mechanical
 ventilation, and extracorporeal life support. This research will provide the needed
 epidemiologic and basic comparative data required to power and conduct a definitive,
 head-to-head trial of DM vs. MP.
Inclusion Criteria:

 -  Inclusion criteria are children 5 to 17 years of age with primary admission diagnoses
 of acute asthma exacerbation or status asthmaticus admitted to the PICU

 Exclusion Criteria:

 -  children with existing tracheostomy, cystic fibrosis, and pulmonary hypertension