25: Determinants of Oral Corticosteroid Responsiveness in Wheezing Asthmatic Youth (Doorway)

Although oral corticosteroids (OCS) are the cornerstone of acute asthma management in the emergency department (ED), recent trials have questioned the efficacy of OCS in preschool-aged children presenting with viral-induced wheezing episodes. The aim of the study was to determine the magnitude, and potential determinants, of OCS responsiveness in children presenting to the ED with moderate or severe asthma. We conducted a prospective multicentre cohort study of children aged 1–17 years presenting to the ED with an acute moderate or severe asthma exacerbation, defined as a Pediatric Respiratory Assessment Measure (PRAM) score of 4–7 or 8–12, respectively. All children received standardized treatment with prednisone or equivalent (2 mg/kg in four sites and 1 mg/kg in one site, maximum: 50 mg) and severity-specific co-interventions (salbutamol with/without ipratropium bromide) as per national guidelines. Key determinants included age, sex, baseline PRAM, site, viral aetiology (polymerase chain reaction [PCR] on nasopharyngeal swabs), tobacco exposure (salivary cotinine) and OCS dose. The primary efficacy endpoint was ED management failure (i.e., hospital admission, prolonged (≥8 hours) ED stay, or a return visit within 72 hours with an admission or prolonged stay). Of the 973 participants, most were preschoolers (75.1%), males (66.3%) and presented with a moderate (72.5%) exacerbation. Children received 2 mg/kg (82.2%) or 1 (17.8%) mg/kg of prednisone or equivalent: 165 (17.1%) experienced ED management failure; 579 (62.1%) had a PCR-confirmed viral infection (45% rhinoviruses; 17.3% respiratory syncythial virus; 9.7% metapneumovirus); 53 (5.3%) had elevated salivary cotinine (≥4 ng/mL); and 260 (26.8%) had suspected (1≤ cotinine <4 ng/mL) or reported environmental tobacco smoke exposure. After adjusting for co-variables, ED management failure was significantly associated with baseline PRAM (OR 1.49 [95% CI 1.34 to1.65], for each additional PRAM point), concurrent pneumonia (OR 4.56 [2.73 to 7.61]) and sites. The two sites with protocolized asthma management initiated by nurses were associated with 50% lower admission rates. Of note, age, sex, PCR-confirmed viral infection, saliva cotinine, and dose/kg of OCS were not significantly associated with the magnitude of response. Preschool age and viral triggers do not increase the risk of ED management failure or poor response to OCS in children. However, increasing severity of the exacerbation, concurrent pneumonia, and sites were significantly associated with ED management failure. In sites with protocolized asthma management, rapid administration of OCS (irrespective of dose) decreased by half the risk of ED treatment failures.

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