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THE USE OF STEROIDS TO TREAT VIRAL INDUCED WHEEZE.

THE USE OF STEROIDS TO TREAT VIRAL INDUCED WHEEZE. GILLIAN HAGGERTY ADVANCED PAEDIATRIC & NEONATAL HEALTH ASSESSMENT SEPTEMBER 2009. INTRODUCTION.

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THE USE OF STEROIDS TO TREAT VIRAL INDUCED WHEEZE.

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  1. THE USE OF STEROIDS TO TREAT VIRAL INDUCED WHEEZE. GILLIAN HAGGERTY ADVANCED PAEDIATRIC & NEONATAL HEALTH ASSESSMENT SEPTEMBER 2009

  2. INTRODUCTION • Viral induced wheeze is common in preschool children (up to 6yrs old), nearly 1/3 of childrenin the UK have the condition, however, the majority of them will grow out of it with only a minority going on to develop interval symptoms & atopic asthma (BTS/SIGN 2009, Bush 2009). • Often parents use the term wheeze to describe any abnormal respiratory noise but it is important to distinguish it from other noises such as rattly breathing or stridor. • BTS/SIGN describe wheeze as - “ a continuous, high pitched musical sound coming from the chest”.

  3. VIRAL INDUCED-WHEEZE OR ASTHMA? • Not all wheezing is asthma. Children with asthma will wheeze at other times (interval symptoms) not just when they have a respiratory virus. • Intermittent wheezing in association with a respiratory virus and no interval symptoms, caused by irritability of the airways rather than inflammation. • Separate entity to asthma and as such use of steroids is questionable. • A small, clinically indistinguishable amount of children will have atopic asthma, therein lies the problem, it is not possible to tell which child will have asthma. (Bush 2009, Frey & Von Mutius 2009, Panickar & Grigg 2006).

  4. CURRENT PRACTISE Currently there are no guidelines for the treatment of preschool viral-induced wheeze, treatment is based on that of asthma and the use of oral steroids is commonplace. The suggestion that steroids may change the course of viral induced wheeze is causing much debate in the medical literature (Bush 2009, Frey & Von Mutius 2009, Panickar & Grigg 2006). As APNPs we will be responsible for assessing & treating the large volumes of children who attend hospitals with this condition and as such it is important to look at the evidence for this practise.

  5. THE QUESTION Do preschool children with viral induced wheeze benefit from treatment with steroids?

  6. SEARCH STRATEGY Via Scottish eLibrary www.elib.scot.nhs.uk/ (accessed 06/09/09) Search terms Child* or paediatric or pediatric or infant Corticosteroid or prednisolone or steroid Respiratory Wheez* Virus or viral Cochrane Library – 22 reviews (none oral steroids & PVW), 17 clinical trials Ovid medline – 194 results Embase – 116 results

  7. INCLUSION/EXCLUSION CRITERIA INCLUDED Must be available on line or locally Pre-school children ( 0 – 6yrs) with viral induced wheeze Hospital initiated Year 2000 – present EXCLUDED Inhaled steroids Diagnosis of asthma, bronchiolitis or specific virus ie. RSV, rhinovirus. Of the search results only two fitted the criteria.

  8. THE ARTICLES Panickar J., Lakhanpaul M., Lambert P., Kenia P., Stephenson T.,Smyth A., Grigg J. (2009) Oral Prednisolone for Preschool Children with Acute Virus-Induced Wheeze. The New England Journal of Medicine 360 (4) 329-338. A double blind randomised controlled trial was conducted in 3 hospitals in the Uk in children aged from 10 months to 6 years with viral-induced wheeze. To determine if a short course of oral prednisolone would improve the outcomes of length of hospital stay and secondary outcomes of score on the Preschool Respiratory assessment Measure, use of salbutamol and a 7 day symptom score.

  9. THE ARTICLES Csonka P., Kaila M., Laippala P., Iso-Mustajarvi M., Vesikari T., Ashorn P. (2003) Oral Prednisolone in the Acute Management of Children Age 6 to 35 Months With Viral Respiratory Infection-Induced Lower Airway Disease: A Randomized, Placebo-Controlled Trial The Journal of Pediatrics 143 725-730. A double blind randomised controlled trial was conducted in a hospital in Finland in children aged between 6 & 35 months, presenting with viral induced respiratory distress (tachypnoea, wheeze or use of accessory muscles), patients with asthma or 2 or more wheezing episodes were not eligible. To investigate the efficacy of a 3 day course of oral prednisolone on exacerbation of symptoms, length of hospital stay and duration of symptoms.

  10. CRITICAL APPRAISAL TOOL Critical Appraisal Skills Programme (Casp) - 10 questions to help you make sense of randomised controlled trials from the Public Health Resource Unit (2006).

  11. WAS A CLEARLY FOCUSED QUESTION ASKED?

  12. WAS THIS A RANDOMISED CONTROL TRIAL?

  13. WERE THE PARTICIPANTS APPROPRIATELY ALLOCATED TO THE GROUPS?

  14. WERE PARTICIPANTS, STAFF & STUDY PERSONNEL BLIND?

  15. WERE ALL THE PARTICIPANTS WHO ENTERED THE TRIAL ACCOUNTED FOR AT ITS CONCLUSION?

  16. WERE THE PARTICIPANTS IN ALL GROUPS FOLLOWED UP & DATA COLLECTED IN THE SAME WAY?

  17. DID THE STUDY HAVE ENOUGH PARTICIPANTS TO MINIMISE THE PLAY OF CHANCE?

  18. HOW ARE THE RESULTS PRESENTED & WHAT IS THE MAIN RESULT?

  19. HOW PRECISE ARE THE RESULTS?

  20. WERE ALL IMPORTANT OUTCOMES CONSIDERED SO THE RESULTS CAN BE APPLIED?

  21. IMPLICATIONS FOR PRACTICE The current approach to treating viral induced wheeze is based on the treatment of asthma – inhaled salbutamol & steroids, with oral steroids for acute exacerbations. However, more & more medical staff are prescribing steroids for wheezing episodes other than acute exacerbations. Managing preschool wheeze is a challenge which is causing much debate in the medical literature (Bush 2009, Frey & Von Mutius 2009, Panickar & Grigg 2006), as it is seen as a separate entity to the classic atopic asthma and should thus be treated differently. From the 2 articles analysed there is little evidence to support the use of steroids in the treatment of viral-induced wheeze in preschool children. The lack of research available & the current debate would suggest that further research is clearly required. Steroids should be prescribed on a case by case basis, particularly in severe attacks and the practise of prescribing them unnecessarily should be stopped. As APNPs we have the opportunity here to directly influence the treatment our patients receive.

  22. REFERENCES BTS, SIGN (2009) British Guideline on the Management of Asthma. Edinburgh Bush A (2009) Practice Imperfect – Treatment for Wheezing in Preschoolers The New England Journal of Medicine 360 (4) 409 Csonka P., Kaila M., Laippala P., Iso-Mustajarvi M., Vesikari T., Ashorn P. (2003) Oral Prednisolone in the Acute Management of Children Age 6 to 35 Months With Viral Respiratory Infection-Induced Lower Airway Disease: A Randomized, Placebo-Controlled Trial The Journal of Pediatrics 143 725-730. Frey U., & Von Mutius E (2009) The Challenge of Managing Wheezing in Infants The New England Journal of Medicine 360 (20) 2130-2133 Panickar J. & Grigg J (2006) Controversies in the management of preschool viral wheeze. Paediatric Respiratory Reviews. 7 293-298 Panickar J., Lakhanpaul m., Lambert P., Kenia P., Stephenson T., Smyth A., Grigg J. (2009) Oral Prednisolone for Preschool Children with Acute Virus-Induced Wheezing. The New England Journal of Medicine. 360 (4) 329-338 Public Health Research Unit (2006). CASP 10 questions to help you make Sense of randomised control trials. www.phru.nhs.uk/Pages/PHD/resources.htm

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