Clinical Question

In children presenting with acute severe asthma, does intravenous aminophylline improve meaningful clinical outcomes compared to standard therapy?

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Background

IV aminophylline has historically been used as a second-line infusion in severe paediatric asthma. However, contemporary escalation strategies increasingly prioritise:

• Oxygen

• High-dose nebulised salbutamol

• Systemic corticosteroids

• IV magnesium sulphate

This raises the question: does aminophylline still offer incremental benefit?

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The Evidence Reviewed

A systematic review published in Archives of Disease in Childhood analysed:

• 9 randomised controlled trials

• 466 children

• Standard therapy ± IV aminophylline

Outcomes assessed:

• Asthma severity scores

• Length of stay

• Admission rates

• PICU admission

• Intubation rates

• Adverse effects

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Key Findings

No significant benefit in:

• Speed of clinical improvement

• Admission rates

• PICU transfer

• Intubation rates

• Length of hospital stay

Significant increase in adverse effects:

• Nausea and vomiting (3–5x higher)

• Headache

• Tremor

• Irritability

• Arrhythmias

Overall: No improvement in meaningful outcomes, with increased morbidity.

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Important Caveat

A 1998 study (Young & South) suggested possible benefit in the most critically unwell, treatment-refractory children, including:

• Reduced duration of intubation

• Potential improvement in lung function

This suggests a potential narrow rescue-therapy window.

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Implications for Paediatric Emergency Practice (2025)

Current best evidence supports:

1. Oxygen

2. Nebulised salbutamol

3. Systemic corticosteroids

4. IV magnesium

5. Structured escalation planning

IV aminophylline should be considered:

• A rescue therapy of last resort

• Not routine second-line treatment

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Take-Home Message

IV aminophylline has historical presence but limited modern evidence of benefit. For most children with acute severe asthma, it increases adverse effects without improving outcomes.

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