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Craig S, Collings M, Gray C, Benito J, Velasco R, Lyttle MD, Roland D, Schuh S, Shihabuddin B, Kwok M, Mahajan P, Johnson M, Zorc J, Khanna K, Fernandes R, Yock-Corrales A, Santhanam I, Cheema B, Ong GYK, Jaiganesh T, Powell C, Nixon G, Dalziel S, Babl FE, Graudins A. Analysis of guideline recommendations for treatment of asthma exacerbations in children: a Pediatric Emergency Research Networks (PERN) study. Arch Dis Child 2024; 109:468-475. [PMID: 38325912 DOI: 10.1136/archdischild-2023-326739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 01/23/2024] [Indexed: 02/09/2024]
Abstract
RATIONALE There is significant practice variation in acute paediatric asthma, particularly severe exacerbations. It is unknown whether this is due to differences in clinical guidelines. OBJECTIVES To describe and compare the content and quality of clinical guidelines for the management of acute exacerbations of asthma in children between geographic regions. METHODS Observational study of guidelines for the management of acute paediatric asthma from institutions across a global collaboration of six regional paediatric emergency research networks. MEASUREMENTS AND MAIN RESULTS 158 guidelines were identified. Half provided recommendations for at least two age groups, and most guidelines provided treatment recommendations according to asthma severity.There were consistent recommendations for the use of inhaled short-acting beta-agonists and systemic corticosteroids. Inhaled anticholinergic therapy was recommended in most guidelines for severe and critical asthma, but there were inconsistent recommendations for its use in mild and moderate exacerbations. Other inhaled therapies such as helium-oxygen mixture (Heliox) and nebulised magnesium were inconsistently recommended for severe and critical illness.Parenteral bronchodilator therapy and epinephrine were mostly reserved for severe and critical asthma, with intravenous magnesium most recommended. There were regional differences in the use of other parenteral bronchodilators, particularly aminophylline.Guideline quality assessment identified high ratings for clarity of presentation, scope and purpose, but low ratings for stakeholder involvement, rigour of development, applicability and editorial independence. CONCLUSIONS Current guidelines for the management of acute paediatric asthma exacerbations have substantial deficits in important quality domains and provide limited and inconsistent guidance for severe exacerbations.
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Affiliation(s)
- Simon Craig
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Department of Paediatric Emergency, Monash Health, Clayton, Victoria, Australia
| | - Madeline Collings
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Charmaine Gray
- Adelaide Medical School, Discipline of Paediatrics, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Paediatric Emergency, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Javier Benito
- Department of Pediatric Emergency, Cruces University Hospital, Bilbao, Basque Country, Spain
- University of the Basque Country, Bilabo, Basque Country, Spain
| | - Roberto Velasco
- Pediatric Emergency Unit, Hospital Universitari Parc Taul, Sabadell, Spain
- Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Research in Emergency Care Avon Collaborative Hub (REACH), University of the West of England, Bristol, UK
| | - Damian Roland
- SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, UK
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Department of Children's Emergency, Leicester Royal Infirmary, Leicester, UK
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- SickKids Research Institute, Toronto, Ontario, Canada
| | - Bashar Shihabuddin
- Division of Emergency Medicine, Nationwide Children's Hospital, Colombus, Ohio, USA
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Maria Kwok
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Pediatric Emergency, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Prashant Mahajan
- Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Mike Johnson
- Department of Pediatrics, Division of Pediatric Emergency Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Joseph Zorc
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kajal Khanna
- Department of Emergency Medicine, School of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ricardo Fernandes
- Department of Pediatrics, Hospital de Santa Maria, Lisboa, Portugal
- Clinical Pharmacology Unit, University of Lisbon, Lisboa, Portugal
| | - Adriana Yock-Corrales
- Department of Emergency, Hospital Nacional de Ninos Dr Carlos Saenz Herrera, C.C.S.S, San Jose, Costa Rica
| | - Indumathy Santhanam
- National Health Mission, Tamil Nadu, India
- PREM Simulation Laboratory, Institute of Child Health, Madras Medical College, Chennai, India
| | - Baljit Cheema
- Department of Paediatrics & Child Health, University of Cape Town Faculty of Health Sciences, Western Cape, South Africa
| | - Gene Yong-Kwang Ong
- Children's Emergency Department, KK Women's and Children's Hospital, Singapore
- Medical School, Duke University and the National University of Singapore, Singapore
| | | | - Colin Powell
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Gillian Nixon
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Department of Respiratory Medicine, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Stuart Dalziel
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Department of Children's Emergency, Starship Children's Health, Auckland, New Zealand
| | - Franz E Babl
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Department of Emergency, Royal Children's Hospital, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Andis Graudins
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Monash Emergency Service, Emergency Department, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia
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Lan J, Plint AC, Dalziel SR, Klassen TP, Offringa M, Heath A. Remote, real-time expert elicitation to determine the prior probability distribution for Bayesian sample size determination in international randomised controlled trials: Bronchiolitis in Infants Placebo Versus Epinephrine and Dexamethasone (BIPED) study. Trials 2022; 23:279. [PMID: 35410375 PMCID: PMC8996198 DOI: 10.1186/s13063-022-06240-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 03/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background Bayesian methods are increasing in popularity in clinical research. The design of Bayesian clinical trials requires a prior distribution, which can be elicited from experts. In diseases with international differences in management, the elicitation exercise should recruit internationally, making a face-to-face elicitation session expensive and more logistically challenging. Thus, we used a remote, real-time elicitation exercise to construct prior distributions. These elicited distributions were then used to determine the sample size of the Bronchiolitis in Infants with Placebo Versus Epinephrine and Dexamethasone (BIPED) study, an international randomised controlled trial in the Pediatric Emergency Research Network (PERN). The BIPED study aims to determine whether the combination of epinephrine and dexamethasone, compared to placebo, is effective in reducing hospital admission for infants presenting with bronchiolitis to the emergency department. Methods We developed a Web-based tool to support the elicitation of the probability of hospitalisation for infants with bronchiolitis. Experts participated in online workshops to specify their individual prior distributions, which were aggregated using the equal-weighted linear pooling method. Experts were then invited to provide their comments on the aggregated distribution. The average length criterion determined the BIPED sample size. Results Fifteen paediatric emergency medicine clinicians from Canada, the USA, Australia and New Zealand participated in three workshops to provide their elicited prior distributions. The mean elicited probability of admission for infants with bronchiolitis was slightly lower for those receiving epinephrine and dexamethasone compared to supportive care in the aggregate distribution. There were substantial differences in the individual beliefs but limited differences between North America and Australasia. From this aggregate distribution, a sample size of 410 patients per arm results in an average 95% credible interval length of less than 9% and a relative predictive power of 90%. Conclusion Remote, real-time expert elicitation is a feasible, useful and practical tool to determine a prior distribution for international randomised controlled trials. Bayesian methods can then determine the trial sample size using these elicited prior distributions. The ease and low cost of remote expert elicitation mean that this approach is suitable for future international randomised controlled trials. Trial registration ClinicalTrials.govNCT03567473 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06240-w.
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Knisley L, Hartling L, Jabbour M, Johnson DW, Lang ES, MacPhee S, Reid S, Scott SD, Sinclair D, Stang AS, Vincent M, Klassen TP. Translating Emergency Knowledge for Kids (TREKK): using research evidence to improve outcomes for children and families in emergency departments across Canada. CAN J EMERG MED 2022; 24:12-15. [PMID: 34625916 PMCID: PMC8500264 DOI: 10.1007/s43678-021-00205-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/24/2021] [Indexed: 10/31/2022]
Affiliation(s)
- Lisa Knisley
- Children's Hospital Research Institute of Manitoba, 532-715 McDermot Avenue, Winnipeg, MB, R3E 3P4, Canada.
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada.
| | - Lisa Hartling
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- Alberta Research Centre for Health Evidence, Edmonton, AB, Canada
| | - Mona Jabbour
- Department of Pediatrics & Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, ON, Canada
| | - David W Johnson
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
- Department of Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Eddy S Lang
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Shannon MacPhee
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sarah Reid
- Department of Pediatrics & Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Shannon D Scott
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Doug Sinclair
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Antonia S Stang
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Matthieu Vincent
- Department of Paediatrics, Faculty of Medicine, McGill University, Montreal, QC, Canada
- Faculty of Medicine, Sherbrooke University, Sherbrooke, QC, Canada
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba, 532-715 McDermot Avenue, Winnipeg, MB, R3E 3P4, Canada
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
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