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Why did you do this work?Wheeze is a common paediatric presentation however there is a lack of evidence regarding the optimum salbutamol weaning regime for discharge. Traditionally, a fixed salbutamol weaning regime instructs parents to give fixed doses that wean over 3 days (e.g. 10 puffs 4 hourly for 24 hours, then 6 puffs 4 hourly for 24 hours, then 2 puffs 4 hourly for 24 hours.)Previous work in our department established that an ‘as required’ salbutamol weaning regime on discharge utilised less salbutamol, was preferred by parents and there were no major changes in reattendance rates in a small cohort. (Connett, 2023).What did you do?In September 2022, an ‘as required’ salbutamol regime was implemented for all children discharged home in our institution following a diagnosis of wheeze in CED. Parents were given verbal and written advice on when to give salbutamol in response to their child’s symptoms. (Harper, 2022) This project evaluated whether reattendance rates increased post-intervention over a longer period and in a larger cohort of patients.A retrospective review was undertaken of all patients diagnosed with wheeze (viral induced wheeze or asthma) between September 2021 and August 2022 (pre-intervention) and September 2022 and August 2023 (post-intervention). The primary outcome was the numbers of patients who reattended within 24 hours and secondary outcomes were the numbers of patients who reattended within 1-7 days, length of time in ED and admissions to HDU or PICU.What did you find?1117 cases attended CED with wheeze pre-intervention (median age 3.2 years, IQR 1.9 – 5.3 years) and 1400 cases post intervention ages (median age 3.6 years IQR 2.1 – 6.6 years). In the pre-intervention group 23/1117 (2.1%) reattended within 24 hours and 33/1117 (3%) reattended within 1-7 days. 1 reattendance was admitted to HDU, none to PICU. The average time following reattendance in the department for the pre-intervention group was 7.9 hours.In the post-intervention group 18/1400 (1.3%) reattended within 24 hours and 21/1400 (1.5%) reattended within 1-7 days. No cases were admitted to HDU/PICU. The average time following reattendance in the department for the post-intervention group was 7.5 hours.According to χ2 testing there was no difference in the rates of reattendance at 24 hours (χ2 [1, n=2517] = 2.319 p = 0.13). There was a reduction in the rates of reattendance within 1-7 days following the intervention (χ2 [1, n=2517] = 6.259 p = 0.01).What does it mean?In this retrospective study, following the introduction of an ‘as required’ salbutamol weaning regime on discharge there was no increase in reattendance rates for patients with wheeze and there is evidence that reattendance rates reduced within 1-7 days. This suggests that an ‘as required’ salbutamol regime on discharge does not lead to an increase in reattendance rates.ReferencesConnett G, Harper S, Raut B, James D. Hospital discharge using salbutamol as required after acute attacks of wheeze in children: a service evaluation. Arch Dis Child. 2023 Dec 14;109(1):2. doi: 10.1136/archdischild-2023-325703. PMID: 37918898; PMCID: PMC10803954.Harper S, Connett G, James D. Wheeze discharge advice. Wessex Healthier Together. 2022 November. https://www.what0-18.nhs.uk/application/files/6916/8088/2923/Wheeze_discharge_plan_Version_13_Nov_2022__FINAL_1.pdf (accessed 30 Sep 2024)

ObjectivesWe changed our clinical practice in to stop giving patients and families ‘weaning plans’ of reducing salbutamol dosage following an asthma exacerbation. We wished to establish if this change in practice was associated with an increase in reattendance or readmission.MethodsWe reviewed all attendances (1554) and admissions (297) for asthma over a 3 year period (18 months prior to the change in practice and 18 months following) We identified reattendance and readmissions, within 48 hours, 7 days and 30 days.ResultsThere was no significant difference between readmissions before or after the change in practice – 1.9 vs 2.7% at 48 hours2.3 vs 1.5% at 7 days7.4 vs 4.7% at 30 days or reattendances0.9 vs 2.2% at 48 hours1.1 vs 1.9 at 7 days3.5 vs 3.5% at 30 days.When looking at patterns of reattendance it was noted 17 individuals with 5 or more reattendances each made up 25% of all reattendance episodes, before and after the change in practice.ConclusionsIn the population and time period studied we did not demonstrate a significant difference in reattendance or readmission following our change in practice.This reduced our usage of salbutamol, and supported our focus on preventer therapies for asthma for professionals and families.There were multiple potential confounders, including coronavirus pandemic and changes to our local asthma pathways and services, however concerns that the removal of weaning plans would significantly increase reattendance were not realised.We will continue to monitor reattendance and readmission rates and intend to focus additional work on identifying those children with particularly high rates for hospital attendance and admission.

Numerous studies have shown that quality improvement methods can reduce the use of medications in the management of bronchiolitis. Our objective is to identify factors related to the overuse of salbutamol in the treatment of bronchiolitis before and after an improvement initiative. Observational study of sociodemographic and clinical factors associated with the use of salbutamol in children diagnosed with bronchiolitis. This was a secondary analysis of a prospective cohort study conducted at 135 primary care (PC) centers and eight pediatric emergency departments (ED) in the Osakidetza/Basque Health Service (Spain) in two epidemic seasons between which a bronchiolitis integrated care pathway (BICP) had been implemented: pre-intervention season from October 2018 to March 2019 and post-intervention season from October 2019 to March 2020. Generalized linear mixed models were used to estimate association of studied variables on use of salbutamol over the two seasons. Four thousand one hundred thirty-four ED attendances and 8573 PC visits were included, of which 1936 (46.8%). And 4067 (47.4%) occurred in the post-intervention period respectively. Six independent risk factors were associated with overuse of salbutamol in both seasons: age ≥ 1 year, aOR 2.32 (2.01 to 2.68) in PC centers, and aOR 6.84 (4.98 to 9.39) in EDs; being seen in the last third of the bronchiolitis season, aOR 1.82 (1.51 to 2.18) in PC centers and aOR 1.78 (1.19 to 2.64) in EDs; making more than one visit to the PC center, aOR 4.18 (3.32 to 5.27) or the ED, aOR 2.06 (1.59 to 2.66); being seen by a general practitioner, aOR 1.97 (1.58 to 2.46) in PC centers; and having a more severe episode, aOR 3.01 (1.89 to 4.79) in EDs.      Conclusion :There are factors associated with salbutamol overuse in children diagnosed with bronchiolitis in PC and emergency settings that persist after the deployment of quality improvement initiatives. What is Known: • Quality improvement initiatives have been shown to decrease the use of non-evidence-based treatments and testing in bronchiolitis. • The magnitude and pattern of change in the use of medications linked to the quality improvement initiatives are not uniform across the same health service. What is New: • Children diagnosed with bronchiolitis ≥ 1 year of age, seen in the last third of the bronchiolitis season, attending more than once, treated by a general practitioner, and/or with more severe episodes are more likely to be treated with salbutamol. • These factors may remain present despite the implementation of improvement initiatives focused on reducing the use of medications in the management of bronchiolitis.

Asthma is a common chronic airway disease worldwide. Despite its large population size, China has had no comprehensive study of the national prevalence, risk factors, and management of asthma. We therefore aimed to estimate the national prevalence of asthma in a representative sample of the Chinese population. A representative sample of 57 779 adults aged 20 years or older was recruited for the national cross-sectional China Pulmonary Health (CPH) study using a multi-stage stratified sampling method with parameters derived from the 2010 census. Ten Chinese provinces, representative of all socioeconomic settings, from six geographical regions were selected, and all assessments were done in local health centres. Exclusion criteria were temporary residence, inability to take a spirometry test, hospital treatment of cardiovascular conditions or tuberculosis, and pregnancy and breastfeeding. Asthma was determined on the basis of a self-reported history of diagnosis by a physician or by wheezing symptoms in the preceding 12 months. All participants were assessed with a standard asthma questionnaire and were classed as having or not having airflow limitation through pulmonary function tests before and after the use of a bronchodilator (400 μg of salbutamol). Risk factors for asthma were examined by multivariable-adjusted analyses done in all participants for whom data on the variables of interest were available. Disease management was assessed by the self-reported history of physician diagnosis, treatments, and hospital visits in people with asthma. Between June 22, 2012, and May 25, 2015, 57 779 participants were recruited into the CPH study. 50 991 (21 446 men and 29 545 women) completed the questionnaire survey and had reliable post-bronchodilator pulmonary function test results and were thus included in the final analysis. The overall prevalence of asthma in our sample was 4·2% (95% CI 3·1–5·6), representing 45·7 million Chinese adults. The prevalence of asthma with airflow limitation was 1·1% (0·9–1·4), representing 13·1 million adults. Cigarette smoking (odds ratio [OR] 1·89, 95% CI 1·26–2·84; p=0·004), allergic rhinitis (3·06, 2·26–4·15; p<0·0001), childhood pneumonia or bronchitis (2·43, 1·44–4·10; p=0·002), parental history of respiratory disease (1·44, 1·02–2·04; p=0·040), and low education attainment (p=0·045) were associated with prevalent asthma. In 2032 people with asthma, only 28·8% (95% CI 19·7–40·0) reported ever being diagnosed by a physician, 23·4% (13·9–36·6) had a previous pulmonary function test, and 5·6% (3·1–9·9) had been treated with inhaled corticosteroids. Furthermore, 15·5% (11·4–20·8) people with asthma reported at least one emergency room visit and 7·2% (4·9–10·5) at least one hospital admission due to exacerbation of respiratory symptoms within the preceding year. Asthma is prevalent but largely undiagnosed and undertreated in China. It is crucial to increase the awareness of asthma and disseminate standardised treatment in clinical settings to reduce the disease burden. National Key R&D Program of China, Ministry of Science and Technology of China; the Special Research Foundation for Public Welfare of Health, Ministry of Health of China; the Chinese National Research Program for Key Issues in Air Pollution Control; and the National Natural Science Foundation of China.

Why did you do this work?Many children receive inhalers for viral-induced wheeze with ~1/3 going on to be diagnosed with asthma.1 Families unaware when inhalers are empty release propellent without medication – dangerous to patient and planet.2 Additionally, traditional high-dose weaning regimens post-attack contribute to salbutamol over-reliance – reducing efficacy, masking deterioration, and increasing greenhouse gases.3–5 Recognising this, 18 months ago our hospital transitioned from salbutamol weaning guidelines to symptom based management post-attack. But has this correlated with sustained changes from staff and families? And what about identifying empty inhalers?What did you do?This service evaluation assessed advice given, and subsequent use of salbutamol, after discharge of the wheezy child – with asthma or viral-induced wheeze (VIW) – from the perspective of staff and service users.Staff knowledge and practice was assessed via a survey of nurses (n=31) and medics (n=23), including questions on what they advise families about salbutamol use immediately post-discharge and how to know if your inhaler is empty.Children attending paediatric A&E with exacerbation of asthma or viral induced wheeze, who hadn’t had specialist asthma nurse review, were identified weekly in April-June 2024 (n=41). Contact rate was 76%, allowing 31 telephone interviews about their knowledge, and advice from staff at their child’s last discharge.What did you find?Only 27% of surveyed staff said they advise symptom based salbutamol post-discharge, with more medics than nurses advising outdated weaning regimens (43%:13%). Only 3% would give correct advice on identifying when a salbutamol inhaler was empty. Staff quoted time, knowledge, and information overload for families as barriers to giving correct information, alongside assuming advice is given by nurses, pharmacists or GPs.Of 31 interviewed families, there was a 2 VIW : 1 asthma ratio and all spoke English as their first language. 1/5 didn’t recall being given any symptom based salbutamol use advice. 55% knew how to track inhaler use and fullness, but this was only discussed correctly at discharge for 1 family. Beat Asthma written information was well utilised and received by families, but often replaced discussions.Abstract 8262 Table 1Selected results from service user feedback on last discharge advice Yes No Correctly advised on symptom based management? 81% (25) 19% (6) (3 advised weaning plan, 2 unsure) Correctly advised on assessing if inhaler is empty? 3% (1) 97% (30) (3 advised incorrectly) What does it mean?Trusts shouldn’t assume guideline adherence, but actively evaluate and improve staff and user knowledge and practice. Written resources are helpful, but may bring accessibility issues and shouldn’t replace discussion. National standards on salbutamol use post-discharge, and including advice on inhaler fullness in The National Respiratory Audit Programme, may improve experience and outcomes.We implemented nursing and medic teaching sessions, are reviewing a standard discharge letter paragraph, and plan to survey and update pharmacists as next steps.ReferencesBloom CI, et al.JACI. 2021.Fullwood I, et al.Arch Dis Child. 2022.3.Connet G, et al. Arch Dis Child. 2023.Warraich S, et al. Breathe (Sheff.), 2023.Levy ML. Breathe (Sheff.), 2015

The study, conducted by a group of international researchers, followed 360 children with mild asthma aged 5 to 15 years across 15 sites in New Zealand for 52 weeks. The researchers found that the annual rate of asthma attacks was nearly halved in the budesonide-formoterol group compared with salbutamol (0.23 v 0.41 per participant per year), a 45% relative reduction (relative risk 0.55, 95% confidence interval 0.35 to 0.86, P=0.012). A new way of managing mild asthma Steve Turner, president of the Royal College of Paediatrics and Child Health and consultant paediatrician in general and respiratory paediatrics at Royal Aberdeen Children’s Hospital, told The BMJ that the “landmark study” might prompt changes in clinical behaviour and guidelines.

IntroductionIncreasingly, hospitals rely on local clinical practice guidelines (CPGs) alongside national guidance to standardise clinical care. This study examines variation between national and local CPGs, using the example of acute paediatric asthma (APA) CPGs from the United Kingdom and the Netherlands.MethodsFifteen British and Dutch local CPGs were collected with the matching national guidance for the management of APA. The drug sequences, routes and methods of administration recommended for patients with severe APA were represented. Deviations from national guidance were measured. Variation in recommended doses of intravenous salbutamol was examined. CPG quality was assessed using the AGREE II instrument.ResultsBritish and Dutch national CPGs differed in the recommended drug choices, sequences, routes and methods of administration for severe APA. Local British CPGs diverged from national guidance for 23% of their recommended interventions compared to 8% for Dutch local CPGs. Variation in second-line recommendations was greater than for first-line recommendations across local CPGs from both countries. Recommended starting doses for salbutamol infusions varied by more than tenfold. The quality of the sampled local CPGs was low across five out of six AGREE domains (<60%).ConclusionsLocal CPGs for the management of severe APA featured substantial variation and frequently diverged from national guidance. Their methodological quality was low. Although limited to one condition, this study suggests that unmeasured variation across local CPGs may contribute to variation of care more broadly, potentially undermining healthcare quality.

ObjectivesChildren born during the Covid-19 pandemic had reduced exposure to early-life respiratory infections compared to pre-pandemic cohorts. This study investigated whether varying level of infection exposure was associated with differing patterns of salbutamol prescription.MethodsA retrospective cohort study using the Northwest London Discover dataset (94% NWL population coverage) including prescription data from General Practice systems. Four birth cohorts were tracked for three years to investigate the impact of Covid-19 on salbutamol prescriptions. Logistic regression assessed cohorts and patient’s characteristics on salbutamol prescriptions.ResultsThere was a significant drop in salbutamol prescriptions during the Covid-19 lockdown followed by a return to pre-pandemic levels as restrictions were lifted (table 1). After adjusting for deprivation, gender and ethnicity, Cohort 2 had 28% lower odds (OR 0.72, 95% CI 0.68–0.77, p<0.001) and Cohort 3 had 18% lower odds (OR 0.82, 95% CI 0.78–0.88, p<0.001) of receiving a salbutamol prescription compared to Cohort 1. Children in Cohort 4, born during the 1st pandemic year, showed salbutamol prescription patterns similar to those in Cohort 1, suggesting a return to pre-pandemic levels.Abstract 6710 Table 1Number and proportion of children receiving salbutamol prescriptions by age for each cohortOverall, males had 43% higher odds of salbutamol prescription compared to females (OR 1.43,95% CI 1.37–1.50, p<0.001). Asian children had 7% lower odds (OR 0.93, 95% CI 0.88–0.98, p<0.05) and Black children had 9% higher odds (OR 1.09, 95% CI 1.00–1.18, p<0.05) compared to White children. Children from most deprived quintile had 16% higher odds (OR 1.16, 95% CI 1.07–1.24, p<0.001) compared to the middle quintile.ConclusionThe Covid-19 pandemic had a major impact on children’s exposure to respiratory infections, significantly affecting salbutamol prescriptions. Ongoing monitoring of these ‘Covid’ cohorts offers a unique opportunity to study the long-term impact of respiratory infections at different stages of childhood.

The optimal dose regimen for intravenous (IV) treatment in children with severe acute asthma (SAA) is still a matter of debate. We assessed the efficacy of adding a salbutamol loading dose to continuous infusion with salbutamol in children admitted to a pediatric intensive care unit (PICU) with SAA. This multicentre, placebo-controlled randomized trial in the PICUs of four tertiary care children’s hospitals included children (2–18 years) with SAA admitted between 2017 and 2019. Children were randomized to receive either a loading dose IV salbutamol (15 mcg/kg, max. 750 mcg) or normal saline while on continuous salbutamol infusion. The primary outcome was the asthma score (Qureshi) 1 h after the intervention. Analysis of covariance models was used to evaluate sensitivity to change in asthma scores. Serum concentrations of salbutamol were obtained. Fifty-eight children were included (29 in the intervention group). Median baseline asthma score was 12 (IQR 10–13) in the intervention group and 11 (9–12) in the control group (p = 0.032). The asthma score 1 h after the intervention did not differ significantly between the groups (p = 0.508, β-coefficient = 0.283). The median increase in salbutamol plasma levels 10 min after the intervention was 13 μg/L (IQR 5–24) in the intervention group and 4 μg/L (IQR 0–7) in the control group (p = 0.001). Side effects were comparable between both groups.Conclusion: We found no clinical benefit of adding a loading dose IV salbutamol to continuous infusion of salbutamol, in children admitted to the PICU with SAA. Clinically significant side effects from the loading dose were not encountered. What is Known:• Pediatric asthma guidelines struggle with an evidence-based approach for the treatment of SAA beyond the initial steps of oxygen suppletion, repetitive administration of inhaled β2-agonists, and systemic steroids.• During an SAA episode, effective delivery of inhaled drugs is unpredictable due to severe airway obstruction.What is New:• This study found no beneficial effect of an additional loading dose IV salbutamol in children admitted to the PICU.• This study found no clinically significant side effects from the loading dose.

Introduction and Objectives Acute asthma is in top ten reasons for paediatric hospital admission in UK.1 with one of the highest mortality rates in Europe.2 Concerns have been raised about discharge bronchodilator regimes used by the majority of hospitals in the UK.3–5 The aim of the quality improvement project was to implement a new hospital bronchodilator dosing regimen (NHBDR) in paediatric emergency department, assessment unit and wards, to support discharge on an ‘as required’ bronchodilator regime and to reduce total bronchodilator dose with potential environmental benefits.Methods We compared 120 children and young patient (CYP) presenting with acute wheeze between December 2023 and January 2024 following the introduction of the NHBDR (figure 1) with 151 CYP presenting between December 2022-February 2023. Data was retrospectively collected from electronic patient record. Comparators included severity of attack, past medical history of wheeze, acute management including nebulised bronchodilators and treatment area, including paediatric emergency department, assessment unit, admission wards. To assess the effectiveness and uptake of the NHBDR, we reviewed the compliance, average number of puffs received, length of stay, readmission rates and the discharge bronchodilator advice. Readmissions and emergency department representations were identified through London Healthcare Records. Patients were grouped according to asthma severity at presentation into mild/moderate, severe and life threatening.Abstract 8425 Figure 1Newly implemented bronchodilator regimen[Figure omitted. See PDF]Results Following implementation of NHBDR, recorded length of stay was reduced by 48.3% for patient with mild/moderate wheeze and 54.3% in patients with severe wheeze on the wards. The average number of puffs administered was reduced by 48% for mild/moderate and by 26% for severe asthma attacks. There was no change in readmission rates or emergency department reattendance. On average, 75% of patients were provided with personal weaning regimen plan (PAAP) upon discharge in 2024 while 85% of patients received standard weaning regimen in 2023. There was an increased severity of acute wheeze presentation in 2024 with multiple life-threatening wheeze presentation. Adherence to the NHBDR was 23/30 in admitted patients.Conclusions A new salbutamol regimen promoting lower doses has been safely implemented across the paediatric unit as a quality improvement project which seemed to reduce length of stay and bronchodilator dosage for patients with moderate and severe acute asthma. This helped promote discharging CYP with an ‘as required’ rather than regular bronchodilator weaning plan. There are potential impacts on cost and environmental considerations.ReferencesKeeble E, L Kossarova. Focus on: emergency hospital care for children and young people. Focus On Report, QualityWatch. 2017Shah, Rakhee, Hagell, Ann, Cheung, Ronny. (2019). International comparisons of health and wellbeing in adolescence and early adulthood.Warraich S, Bush A, Levy ML, Fleming L. Regular (up to 10 puffs 4-hourly) inhaled salbutamol should be prescribed at discharge after an asthma attack: myth or maxim? Breathe (Sheffield, England) 19(3):230054.Asthma deaths in children in the UK: the last straw!Mark L Levy, Louise Fleming and Andrew Bush. British Journal of General Practice 2024;74(743):244–245.Hannah R, Chavasse RJPG, Paton JY, et al. Emergency department discharge practices for children with acute wheeze and asthma: a survey of discharge practice and review of safety netting instructions in the UK and Ireland. Arch Dis Child. 2024;109(7):536–542. Published 2024 Jun 19. doi:10.1136/archdischild-2023-326247