Respiratory Disease
Selected Papers from the 1999 Society for Academic Emergency Medicine Meetings
CONFERENCE COVERAGE
Respiratory Disease
What Route for Dexamethasone in Croup?
Rittichier and colleagues ask the simple question, "why not the PO route for dexamethasone in croup?" Patients with moderate croup (history or presence of stridor) were randomized to intramuscular or oral dexamethasone at 0.6 mg/kg to a maximum of 8.0 mg. Telephone follow-up demonstrated similar outcomes in each group—half were resolved, about one-third returned for re-evaluation, and one-tenth needed either more steroids, nebulized epinephrine, or admission. No adverse sequelae were reported for either group.
Comment by Richard Hamilton, MD, FAAEM, ABMT
This study is simple in design and end point. Of course, since no difference was found, I look forward to the power analysis in the completed paper. However, the differences in absolute terms were so minimal, I believe that the oral route is essentially the same as intramuscular in efficacy. These are the kinds of studies that help me see patients faster and more confidently. While I have always used oral prednisone for asthmatics, I have only rarely used oral dexamethasone. The savings in effort and avoiding needless injection makes this a study that shapes my practice—well done, and bring on the winter! (Source: Rittichier KK, et al. Outpatient treatment of moderate croup with dexamethasone: Intramuscular versus oral dosing [abstract]. Acad Emerg Med 1999;6:493.)
Magnesium Sulfate and Asthma
Alter and associates reviewed 164 papers on magnesium sulfate and asthma. They performed a meta-analysis on seven trials that specifically studied the use of a 1.2-2.0 gram bolus of magnesium sulfate on spirometric function in acute bronchospasm. Magnesium sulfate improved spirometric functions by one-quarter of a standard deviation. In addition, there were no serious adverse events.
Comment by Richard Hamilton, MD
The authors’ effort to make statistical sense of the studies done for magnesium in asthma is laudable. I have never routinely used magnesium in asthma because I have never been convinced of its efficacy. Admittedly, the central problem with clinical asthma studies is the end point. In every case, we are forced to accept surrogate markers of improvement, such as better peak flow rates or hospital discharge. I remain convinced that we achieve better clinical outcomes when we maximize b2 agonist and corticosteroid therapy. Nonetheless, in this meta-analysis, magnesium appears to provide a small benefit in spirometric function as a surrogate marker for asthma severity and may be clinically useful without serious harm. (Source: Alter HJ, et al. Intravenous magnesium sulfate as an effective adjuvant in acute bronchospasm: A meta-analysis [abstract]. Acad Emerg Med 1999;6:521.)
The meta-analysis by Alter et al on the use of magnesium sulfate in acute asthma showed:
a. no advantage in the magnesium-treated patients.
b. no serious adverse effects.
c. an increase in spirometric function only in those patients with adverse effects.
d. improved spirometric function if the magnesium was delivered by aerosol.
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