Hospital Discharge Using Salbutamol as Required After Acute Attacks of Wheeze in Children: A Service Evaluation

To assess the effectiveness of as-needed salbutamol (albuterol) versus scheduled salbutamol upon discharge from the hospital from an acute asthma exacerbation.The study included families of 103 children who presented to Southampton Children’s Hospital in London with acute wheezing episodes requiring burst therapy or back-to-back nebulizers and had a discharge diagnosis of acute wheeze or asthma. Inclusion criteria in the intervention group included wheezing children from 1 to 18 years old who were provided detailed discharge instructions. These results were compared with those of a similar group of hospitalized children with a discharge diagnosis of acute wheeze or asthma from the same 6 months in the preceding year.Pediatric emergency department or hospitalized wheezing patients were provided discharge instructions to use salbutamol metered dose inhaler on an as-needed basis instead of previously accepted asthma pathway protocols, which recommended scheduled doses of salbutamol with weaning over 3 days. Families were given a color-coded flowchart, age-specific instructions for metered dose inhaler and spacer use, video demonstrations, and a table to record salbutamol use. After discharge, a pediatric respiratory nurse specialist called the family for a follow-up within 3 to 5 days.Families reported less salbutamol use after discharge compared with the expected use of salbutamol on a fixed 4-hour wean (day 1: 10 puffs, day 2: 5 puffs, day 3: 2 puffs). Mean estimated doses were reduced by 73% on day 1, 69% on day 2, and 50% on day 3. Eight patients went to their primary care doctor for ongoing symptoms within 2 weeks of discharge. Parents preferred the as-needed basis of salbutamol compared with the prior fixed-dose regimen. The study compared readmission rates to the previous year (2021) when a fixed-dose regimen was used. For the fixed-dose regimen in 2021, the readmission rate to the hospital was 12.5 per 1000. For the as-needed dosing, the readmission rate was 8.3 per 1000, with the odds ratio being 0.66 (0.37–1.14), P = .12. Age was a factor related to readmission with children > 5 years, which showed a decrease in readmission (446 in 2021 vs 247 in 2022). Readmission rates for children < 5 years were similar (571 in 2021 and 510 in 2022).The study demonstrates that as-needed dosing of salbutamol is a safe way to discharge patients after an acute wheezing episode with proper education and does not lead to worsening asthma or higher readmission rates.Many standard asthma protocols and algorithms recommend fixed-dose regimens of short-acting beta-agonists on discharge from the hospital or emergency department every 4 hours for 2 to 3 days. Albuterol dosing schedules continue to promote SABA overreliance and mixed messages for families on the use of short-acting beta-agonists in asthma. GINA 2024 states that short-acting beta-agonists should be used on an as-needed basis following discharge for an exacerbation to avoid masking worsening asthma. GINA also states that patients on inhaled corticosteroid-formoterol, following an exacerbation, should return to inhaled corticosteroid-formoterol as their reliever inhaler before discharge to reduce the risk of using a bronchodilator without an anti-inflammatory.