Dexamethasone Administration for Mild Bronchoconstriction

Question#: 671

Question:

 If a patient receives salbutamol for bronchoconstriction under the bronchoconstriction protocol and improves to a patient condition where they feel they are no longer in respiratory distress with little to no indications of bronchoconstriction still being present, should dexamethasone still be administered as a preventative treatment ?

Answer:

With respect to bronchoconstriction, the mainstay treatment modalities are short acting beta agonists, oxygen PRN (titrated to maintain a patient’s oxygen saturation between 92-96%), and now, the addition of steroids.

There is a wide body of literature supporting the use of corticosteroids in asthma exacerbations, and the positive benefits are well established. A short course of steroids significantly reduces the likelihood of a repeat severe exacerbation within the succeeding two weeks, reduces relapse, lessens the frequency of persistent severe symptoms, reduced the needs for subsequent hospitalizations, reduces the length of stay for admitted patients, and has been shown to decrease time to resolution of symptoms and lead to earlier improvement for lung function and symptomology.

The extant pediatric literature shows similar benefits. While oral corticosteroids are frequently administered to children presenting with mild respiratory symptoms, there is a paucity of research demonstrating clear evidence of benefit in this cohort. While children having a mild case of bronchoconstriction tend to only need single doses of Ventolin, dexamethasone is still routinely given in the ED (in fact is it built into their algorithms as well). Ultimately, the benefit is likely to outweigh any potential harm.

Having said that, for patients experiencing a moderate asthma exacerbation (PRAM 4-7) “Administration of oral corticosteroids just before or immediately after initiating bronchodilator therapy substantially decreases respiratory distress within 2-6 hours of treatment and substantially decreases hospitalization rates.” If you’re curious about the PRAM score, you can check out TREKK (https://trekk.ca/resources?tag_id=D001249) or review our previous CME content from Spring 2022 (https://mediclearn.rppeo.ca/course/view.php?id=691).

Ultimately, while Ventolin should be administered to patients BEFORE you consider administration of dexamethasone, there is downstream benefit to the early administration of steroids.

In summary, dexamethasone is indicated for bronchoconstriction in all but the mildest of cases. Arguably anyone calling 911 with bronchoconstriction meets the threshold for dexamethasone administration, and the downside risk is minimal when compared to the benefits.

References:

https://www.uptodate.com/contents/acute-exacerbations-of-asthma-in-adults-home-and-office-management?search=asthma%20exacerbation%20adult&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H3535982939

https://www.uptodate.com/contents/acute-exacerbations-of-asthma-in-adults-emergency-department-and-inpatient-management?search=asthma%20exacerbation%20adult&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000195.pub2/full

https://trekk.ca/resources?tag_id=D001249