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Pediatric emergency department outcomes comparing levalbuterol vs

Timothy R. Myers BS, RRT, Marsha Rogers CRT, John C. Carl MD, Carolyn Kercsmar MD. Rainbow Babies & Children’s Hospital. Cleveland, Ohio. Background: Pediatric asthma is a chronic condition of childhood with increasing prevalence. Emergency
Department (ED) treatment of asthma constitutes a failure in outpatient management. Frequently, ED
asthma treatment is unsuccessful and patients are admitted. Our ED data the past 5 years yielded an average
admission rate of approximately 41%. The purpose of this study was to determine if levalbuterol resulted in
improved clinical outcomes compared to racemic albuterol. Specifically, we sought to observe a decrease
in admission rate. Methods: An a priori analysis powered at 80% (p-value <0.05) indicated a need to
randomize 532 children to detect a 10% decrease in admission rate. Patients who consented for
participation were randomized in a double-blind fashion to receive either 2.5 mg albuterol or 1.25 mg
levalbuterol delivered by a high-density Nebutech (Salter Labs, Irvine, Ca.) nebulizer. We utilized our
assessment-driven ED Asthma Carepath (ED-ACP) to control for treatment standardization between
groups. Our ED-ACP standardizes assessments & therapy (oxygen, albuterol aerosols, corticosteriods) at
prescribed intervals. Assessments and /or treatments were delivered every 20 minutes. Intensification of
therapy was provided with either subcutaneous epinephrine (SQ Epi) injection (initially) and/or
Ipratropium (during therapy). Treatment was discontinued when discharge criteria were met: good air
exchange, mild / absent end expiratory wheezing, no accessory muscle usage, SpO2 > 93%, and respiratory
rate<40/min. Patients were observed for one hour after their last treatment then discharged. Patients not
meeting discharge criteria after 6 aerosols or 1 hour of continuous aerosols were admitted or transferred. A
chronic asthma severity was assigned based on history, symptoms, and therapeutic drug usage. Fisher Exact
Tests were used to compare race, gender, and administration of SC Epi & Ipratropium. A Pearson chi -
square was used to compare chronic severity & admit vs. discharge status. Unpaired t-tests were used to
compare age, ED LOS, initial SpO2 & aerosols delivered. Significance was set at p < 0.05. Results: This
study randomized 552 children to treatment. Below are demographic and clinical outcome data reported as
raw, mean (SD) or percentages with p-values.


Racemic Albuterol
Outcome Data

Levalbuterol resulted in a clinical and statistical decrease in admission rate and treatments
provided in our ED. An 8% decrease in hospital admission rate could result in a net savings of
approximately $200,000 per year at our institution.


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