Salbutamol 100micrograms/dose / Ipratropium 20micrograms/dose inhaler

ObjectivesTo review the efficacy of nebulised magnesium sulfate (MgSO4) in acute asthma in children.MethodsThe authors searched Medline, Embase, Web of Science and Cochrane Library for randomised controlled trials (RCTs) published until 15 December 2023. RCTs were included if they compared the efficacy and safety of nebulised MgSO4 as a second-line agent in children presenting with acute asthma exacerbation. A random-effects meta-analysis was performed, and the Risk of Bias V.2 tool was used to assess the biases among them.Results10 RCTs enrolling 2301 children with acute asthma were included. All trials were placebo controlled and administered nebulised MgSO4/placebo and salbutamol (±ipratropium bromide). There was no significant difference in Composite Asthma Severity Score between the two groups (6 RCTs, 1953 participants; standardised mean difference: -0.09; 95% CI: -0.2 to +0.02, I2=21%). Children in the MgSO4 group have significantly better peak expiratory flow rate (% predicted) than the control group (2 RCTs, 145 participants; mean difference: 19.3; 95% CI: 8.9 to 29.8; I2=0%). There was no difference in the need for hospitalisation, intensive care unit admission or duration of hospital stay. Adverse events were minor, infrequent (7.3%) and similar among the two groups.ConclusionsThere is low-certainty evidence that nebulised MgSO4 as an add-on second-line therapy for acute asthma in children does not reduce asthma severity or a need for hospitalisation. However, it was associated with slightly better lung functions. The current evidence does not support the routine use of nebulised MgSO4 in paediatric acute asthma management.Prospero registration numberCRD42022373692.

Abstract licence: CC BY-NC

IntroductionPediatric critical asthma is one of the most common pediatric illnesses in children admitted to the pediatric ward and pediatric intensive care unit (PICU). Adjunct intravenous (IV) bronchodilators are often used when initial management with systemic corticosteroids and inhaled short-acting beta agonists (SABA) fail to provide improvement in a patient's clinical condition. While the recent guidelines gave recommendations for the use of different IV bronchodilators compared to placebo, it did not include ranking on which one should be used as first-line or second-line agent. The aim of this network meta-analysis is to determine the effect of IV bronchodilators on patient-centered outcomes and rank medications based on their effectiveness in these outcomes.MethodsA systematic review was conducted using three databases MEDLINE, Embase, and CINAHL to identify randomized control trials examining the use of IV magnesium sulfate (MgSO4), IV methylxanthines (aminophylline or theophylline), IV SABA (salbutamol, terbutaline) in pediatric critical asthma patients. Bayesian network metanalytic framework was used to compare the interventions. Results are reported as odds ratio (OR) or mean difference (MD) and 95% Credible Interval (CrI).ResultsTwelve trials (n = 852) were included in the network meta-analysis. Largest reduction in hospital length of stay (LOS), PICU admission, and PICU LOS were noted with IV MgSO4; (MD: -3.1 days, 95% CrI: -6.9 days to 0.13 days), (OR 0.21; 95% CrI 0.02, 1.3), and (MD: -4.0 days, 95% CrI: -7.1 days to -1.2 days) respectively. IV MgSO4 was ranked first in three outcomes of interest with Surface Under the Cumulative Ranking curve (SUCRA) of 0.884 for hospital LOS, 0.919 for PICU admission, and 0.957 for PICU LOS. For preventing intubation, IV SABA was ranked the highest (SUCRA 0.995), but the only study with IV SABA had zero intubation events. In a sensitivity analysis that excluded studies with zero events, the intubation rate was lowest with IV MgSO4 (OR 0.10; 95% CrI 0.003, 0.88) and it was ranked the best treatment (SUCRA 0.921).ConclusionsIn this network meta-analysis comparing different IV adjunct bronchodilators, IV MgSO4 was ranked first followed by IV SABA, and then IV methylxanthines. Given these findings and the favorable safety profile, ease of use, and low cost, IV MgSO4 appears most promising the first adjunct IV bronchodilator, however, further large high-quality trials are still needed before it can be endorsed as routine first-line agent.

Abstract licence: CC BY-NC-ND