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Epinephrine and Theophylline/Aminophylline

Question 3:

In the child with an asthma exacerbation in the ED, should intramuscular epinephrine and/or theophylline/aminophylline be used to prevent hospitalization, to decrease time in the ED, and/or to improve pulmonary function?

Asthma ED team recommendation:

The Asthma ED Team recommends using intramuscular epinephrine for children in impending/actual respiratory arrest based on very low quality evidence (Consensus). We value preventing the need of mechanical ventilation via the use of parenteral beta agonists. We base this decision on clinical expertise regarding the use of epinephrine in cases of impending respiratory failure. EPR-3 (2007) states parenteral beta agonists have no proven advantage over aerosol therapy. Further research is likely to have an important influence on our confidence in the estimate of effect and may change the estimate of the effect.

Literature supporting this recommendation: Literature was searched since the publication of EPR-3. (2007). No literature was found to support this recommendation.

EPR-3 (2007) does not recommend the use of methylxanthines. Specifically in the ED theophylline/aminophylline are not recommended because they appear to provide no additional benefit to optimal SABA therapy and increases the frequency of adverse effects If patients are currently taking a theophylline-containing preparation, determine serum theophylline concentration to prevent theophylline toxicity.

The Asthma ED team concurs that methylxanthines should not be added to the treatment of acute asthma for children presenting to the ED, even for those patients with the most severe exacerbations. The D'Avila (2008) study did not demonstrate a decrease in hospital admission using this treatment. We put high value on avoiding a treatment that has not shown efficacy. The recommendation may apply to most patients in most circumstances. Further research is unlikely to change our confidence in the estimate of effect.

See supporting literature for this recommendation: Literature was searched since the publication of EPR-3 (2007). One study randomized control trial since EPR-3 (2007) was identified.

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.