The Preschool Respiratory Assessment Measure (PRAM): a responsive index of acute asthma severity

Validity of bronchiolitis outcome measures

BACKGROUND

The Respiratory Distress Assessment Instrument (RDAI) and Respiratory Assessment Change Score (RACS) are frequently used in bronchiolitis clinical trials, but evidence is limited on their measurement properties. We investigated their validity, reliability, and responsiveness.

METHODS

We included data from up to 1765 infants with bronchiolitis enrolled in 2 studies conducted in pediatric emergency departments. We assessed RDAI construct validity by testing hypotheses of associations with physiologic measures (respiratory rate, oxygen saturation) and with constructs related to hospitalization, using correlation coefficients, and multivariable analysis. RDAI/RACS responsiveness was evaluated by using anchors of change based on these constructs; measures of responsiveness included the area under the curve. RDAI test-retest agreement and interrater reliability were evaluated by using limits of agreement and intraclass correlation coefficients.

RESULTS

Baseline RDAI scores were weakly correlated with respiratory rate (r = 0.38, P < .001), and scores increased in lower oxygen saturation categories (P < .001). Higher RDAI scores were associated with hospitalization (odds ratio: 1.36; 95% confidence interval: 1.26-1.47); scores differed between participants who were discharged, admitted, or stayed in the emergency department (P < .001). Our hypotheses were met, but the magnitude of associations was below our predefined thresholds. RDAI test-retest limits of agreement were -3.80 to 3.64 (20% of the range), whereas interrater reliability was good (intraclass correlation coefficient = 0.93). Formulated hypotheses for responsiveness were confirmed, with moderate responsiveness (area under the curve: RDAI, 0.64-0.70; RACS, 0.72).

CONCLUSIONS

RDAI has poor to moderate construct validity, with good discriminative properties but considerable test-retest measurement error. The RDAI and RACS are responsive measures of respiratory distress in bronchiolitis but do not encompass all determinants of disease severity.

Diagnosis and management of asthma in preschoolers: A Canadian Thoracic Society and Canadian Paediatric Society position paper

Asthma often starts before six years of age. However, there remains uncertainty as to when and how a preschool-age child with symptoms suggestive of asthma can be diagnosed with this condition. This delays treatment and contributes to both short- and long-term morbidity. Members of the Canadian Thoracic Society Asthma Clinical Assembly partnered with the Canadian Paediatric Society to develop a joint working group with the mandate to develop a position paper on the diagnosis and management of asthma in preschoolers. In the absence of lung function tests, the diagnosis of asthma should be considered in children one to five years of age with frequent (≥ 8 days/month) asthma-like symptoms or recurrent (≥ 2) exacerbations (episodes with asthma-like signs). The diagnosis requires the objective document of signs or convincing parent-reported symptoms of airflow obstruction (improvement in these signs or symptoms with asthma therapy), and no clinical suspicion of an alternative diagnosis. The characteristic feature of airflow obstruction is wheezing, commonly accompanied by difficulty breathing and cough. Reversibility with asthma medications is defined as direct observation of improvement with short-acting ß2-agonists (SABA) (with or without oral corticosteroids) by a trained health care practitioner during an acute exacerbation (preferred method). However, in children with no wheezing (or other signs of airflow obstruction) on presentation, reversibility may be determined by convincing parental report of a symptomatic response to a three-month therapeutic trial of a medium dose of inhaled corticosteroids with as-needed SABA (alternative method), or as-needed SABA alone (weaker alternative method). The authors provide key messages regarding in whom to consider the diagnosis, terms to be abandoned, when to refer to an asthma specialist and the initial management strategy. Finally, dissemination plans and priority areas for research are identified.

PCR testing for paediatric acute respiratory tract infections

Acute respiratory tract infection (ARI) is a frequently occurring disease in children. It is a clinical diagnosis for which no internationally accepted diagnostic test is available. The majority of ARI is viral in origin, though diagnostic tests for viruses were rarely performed in the past. In the past 2 decades, new molecular techniques have been introduced in many hospitals. They are capable of generating a high yield of viral and bacterial diagnoses, but their impact upon clinical practices is still questionable. In this paper, we discuss the difficulties of diagnosing ARI in children, the indications for conventional and new diagnostics and their implications.

Modified pulmonary index score was sufficiently reliable to assess the severity of acute asthma exacerbations in children

BACKGROUND

The Modified Pulmonary Index Score (MPIS) was developed as an indicator of the severity of acute asthma in children. The objective of this study is to evaluate the reliability and validity of the MPIS for children with acute asthma, including those five years or younger in age.

METHODS

We evaluated the inter-rater reliability and internal consistency of the MPIS by having at least two trained physicians and a nurse-each of whom was blinded to the others' scores-simultaneously examine inpatients with asthma exacerbation and rate them according to the MPIS. We also evaluated the intraclass correlation coefficient (ICC), kappa, Cronbach's α and correlations between the MPIS and other indicators associated with asthma severity.

RESULTS

A total of 25 children (median age, five years; 13 patients were five years or younger in age) were enrolled in this study. The MPIS showed excellent inter-rater reliability (all ages: ICC = 0.95, 95% CI = 0.94-0.97; five years or younger: ICC = 0.93, 95% CI = 0.89-0.96) and good internal consistency (all ages: Cronbach's α = 0.87; five years or younger: Cronbach's α = 0.85). The MPIS showed good correlation with a visual analogue scale assessed by the physicians.

CONCLUSIONS

The MPIS was a sufficiently reliable assessment tool for children with acute asthma, including those five years or younger in age.

Interobserver reliability of attending physicians and bedside nurses when using an inpatient paediatric respiratory score

AIMS AND OBJECTIVES

This study aimed to determine the interobserver reliability between bedside nurses and attending physicians for a paediatric respiratory score as part of an asthma Integrated Care Pathway implementation.

BACKGROUND

An Integrated Care Pathway is one approach to improving quality of care for children hospitalised with asthma. Prior to implementation of the integrated care pathway, it was necessary to train nursing staff on the use of a respiratory assessment tool and to evaluate the interobserver reliability use of this tool.

DESIGN

Prospective study using a convenience sample of children hospitalised for a respiratory illness in an academic medical centre.

METHODS

The respiratory assessment used was the Paediatric Asthma Score. Bedside nurse-attending physician (27 different RNs and three attending paediatric hospitalists) pairs performed 71 simultaneous patient assessments on 20 patients. Intraclass correlation coefficient and kappa statistics were used to assess interobserver reliability.

RESULTS

The overall intraclass correlation coefficient was nearly perfect where κ = 0·95, 95% CI (0·92, 0·97) and overall kappa for reliability based on clinically relevant score breakpoints was also high with κ = 0·82, 95% CI (0·75, 0·90). The majority of subgroup analyses revealed substantial to almost perfect agreement across a variety of diagnoses, age ranges, and individual score components.

CONCLUSIONS

Bedside nurses, with support and training from attending physicians, can perform respiratory assessments that agree almost perfectly with those of attending physicians.

RELEVANCE TO CLINICAL PRACTICE

The use of an Integrated Care Pathway allows for optimal interprofessional collaboration between bedside nurses and attending physicians.

Toward patient-centered care: a systematic review of how to ask questions that matter to patients

Clinicians rarely systematically document how their patients are feeling. Single item questions have been created to help obtain and monitor patient relevant outcomes, a requirement of patient-centered care.The objective of this review was to identify the psychometric properties for single items related to health aspects that only the patient can report (health perception, stress, pain, fatigue, depression, anxiety, and sleep quality). A secondary objective was to create a bank of valid single items in a format suitable for use in clinical practice.Data sources used were Ovid MEDLINE (1948 to May 2013), EMBASE (1960 to May 2013), and the Cumulative Index to Nursing and Allied Health Literature (1960 to May 2013).For the study appraisal, 24 articles were systematically reviewed. A critical appraisal tool was used to determine the quality of articles.Items were included if they were tested as single items, related to the construct, measured symptom severity, and referred to recent experiences.The psychometric properties of each item were extracted. Validity and reliability was observed for the items when compared with clinical interviews or well-validated measures. The items for general health perception and anxiety showed weak to moderate strength correlations (r = 0.28-0.70). The depression and stress items showed good area under the receiver operating characteristic curve of 0.85 and 0.73-0.88, respectively, with high sensitivity and specificity. The fatigue item demonstrated a strong effect size and correlations up to r = 0.80. The 2 pain items and the sleep item showed high reliability (intraclass correlation coefficient [ICC] = 0.85, κ = 0.76, ICC = 0.9, respectively).The search targeted articles about psychometric properties of single items. Articles that did not have this as the primary objective may have been missed. Furthermore, not all the articles included had the complete set of psychometric properties for each item.There is sufficient evidence to warrant the use of single items in clinical practice. They are simple, easily implemented, and efficient and thus provide an alternative to multi-item questionnaires. To facilitate their use, the top performing items were combined into the visual analog health states, which provides a quick profile of how the patient is feeling. This information would be useful for regular long-term monitoring.

Altered exhaled biomarker profiles in children during and after rhinovirus-induced wheeze

Preschool rhinovirus-induced wheeze is associated with an increased risk of asthma. In adult asthma, exhaled volatile organic compounds (VOC) are associated with inflammatory activity. We therefore hypothesised that acute preschool wheeze is accompanied by a differential profile of exhaled VOC, which is maintained after resolution of symptoms in those children with rhinovirus-induced wheeze. We included 178 children (mean±sd age 22±9 months) from the EUROPA cohort comparing asymptomatic and wheezing children during respiratory symptoms and after recovery. Naso- and oropharyngeal swabs were tested for rhinovirus by quantitative PCR. Breath was collected via a spacer and analysed using an electronic nose. Between-group discrimination was assessed by constructing a 1000-fold cross-validated receiver operating characteristic curve. Analyses were stratified by rhinovirus presence/absence. Wheezing children demonstrated a different VOC profile when compared with asymptomatic children (p<0.001), regardless of the presence (area under the curve (AUC) 0.77, 95% CI 0.07) or absence (AUC 0.81, 95% CI 0.05) of rhinovirus. After symptomatic recovery, discriminative accuracy was maintained in children with rhinovirus-induced wheeze (AUC 0.84, 95% CI 0.06), whereas it dropped significantly in infants with non-rhinovirus-induced wheeze (AUC 0.67, 95% CI 0.06). Exhaled molecular profiles differ between preschool children with and without acute respiratory wheeze. This appears to be sustained in children with rhinovirus-induced wheeze after resolution of symptoms. Therefore, exhaled VOC may qualify as candidate biomarkers for early signs of asthma.

Severity of respiratory signs and symptoms and virus profiles in Japanese children with acute respiratory illness

Associations between the severity of respiratory signs and symptoms and the respiratory viruses identified in 214 Japanese children with acute respiratory illness (ARI) enrolled between January and December 2012 were studied. Respiratory rate, wheezing, cyanosis, and the use of accessory muscles were used as indices of respiratory severity and phylogenetic analysis of the viruses identified in these children was performed. Respiratory viruses such as respiratory syncytial virus (RSV), human rhinovirus (HRV), human parainfluenza virus (HPIV), and human metapneumovirus (HMPV) were prevalent, being detected in approximately 70% of the patients (151/214 patients). Co-detection of viruses occurred in about 9% of patients. RSV was identified more frequently in cases scored as moderate/severe than in those scored as mild (P < 0.05). Severity scores of patients with RSV were significantly higher than those of cases with HPIV. Moreover, severity scores in patients with mild disease and co-detections were higher than in those in whom only HPIV or adenovirus was detected. Phylogenetic analysis showed that many genotypes of HRV-A and -C with wide genetic divergence were associated with acute respiratory illness (ARI). On the other hand, only a limited number of genotypes of RSV were associated with ARI. HPIV and HMPV were associated with ARI at similar frequencies. These results suggest that different respiratory viruses with unique genetic characteristics can be found in patients with mild to severe ARI.

Determinants Of Oral corticosteroid Responsiveness in Wheezing Asthmatic Youth (DOORWAY): protocol for a prospective multicentre cohort study of children with acute moderate-to-severe asthma exacerbations

INTRODUCTION

Oral corticosteroids are the cornerstone of acute asthma management in the emergency department. Recent evidence has raised doubts about the efficacy of this treatment in preschool-aged children with viral-induced wheezing and in smoking adults. The aims of the study were to: (1) document the magnitude of response to oral corticosteroids in children presenting to the emergency department with moderate or severe asthma; (2) quantify potential determinants of response to corticosteroids and (3) explore the role of gene polymorphisms associated with the responsiveness to corticosteroids.

METHODS AND ANALYSIS

The design is a prospective cohort study of 1008 children aged 1-17 years meeting a strict definition of asthma and presenting with a clinical score of ≥4 on the validated Pediatric Respiratory Assessment Measure. All children will receive standardised severity-specific treatment with prednisone/prednisolone and cointerventions (salbutamol with/without ipratropium bromide). Determinants, namely viral aetiology, environmental tobacco smoke and single nucleotide polymorphism, will be objectively documented. The primary efficacy endpoint is the failure of emergency department (ED) management within 72 h of the ED visit. Secondary endpoints include other measures of asthma severity and time to recovery within 7 days of the index visit. The study has 80% power for detecting a risk difference of 7.5% associated with each determinant from a baseline risk of 21%, at an α of 0.05.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from all participating institutions. An impaired response to systemic steroids in certain subgroups will challenge the current standard of practice and call for the immediate search for better approaches. A potential host-environment interaction will broaden our understanding of corticosteroid responsiveness in children. Documentation of similar effectiveness of corticosteroids across determinants will provide the needed reassurance regarding current treatment recommendations.

RESULTS

Results will be disseminated at international conferences and manuscripts targeted at emergency physicians, paediatricians, geneticists and respirologists.

TRIAL REGISTRATION NUMBER

This study is registered at Clinicaltrials.gov (NCT02013076).

Systematic review: insufficient validation of clinical scores for the assessment of acute dyspnoea in wheezing children

BACKGROUND

A reliable, valid, and easy-to-use assessment of the degree of wheeze-associated dyspnoea is important to provide individualised treatment for children with acute asthma, wheeze or bronchiolitis.

OBJECTIVE

To assess validity, reliability, and utility of all available paediatric dyspnoea scores.

METHODS

Systematic review. We searched Pubmed, Cochrane library, National Guideline Clearinghouse, Embase and Cinahl for eligible studies. We included studies describing the development or use of a score, assessing two or more clinical symptoms and signs, for the assessment of severity of dyspnoea in an acute episode of acute asthma, wheeze or bronchiolitis in children aged 0-18 years. We assessed validity, reliability and utility of the retrieved dyspnoea scores using 15 quality criteria.

RESULTS

We selected 60 articles describing 36 dyspnoea scores. Fourteen scores were judged unsuitable for clinical use, because of insufficient face validity, use of items unsuitable for children, difficult scoring system or because complex auscultative skills are needed, leaving 22 possibly useful scores. The median number of quality criteria that could be assessed was 7 (range 6-11). The median number of positively rated quality criteria was 3 (range 1-5). Although most scores were easy to use, important deficits were noted in all scores across the three methodological quality domains, in particular relating to reliability and responsiveness.

CONCLUSION

None of the many dyspnoea scores has been sufficiently validated to allow for clinically meaningful use in children with acute dyspnoea or wheeze. Proper validation of existing scores is warranted to allow paediatric professionals to make a well balanced decision on the use of the dyspnoea score most suitable for their specific purpose.

An official American Thoracic Society workshop report: optimal lung function tests for monitoring cystic fibrosis, bronchopulmonary dysplasia, and recurrent wheezing in children less than 6 years of age

Although pulmonary function testing plays a key role in the diagnosis and management of chronic pulmonary conditions in children under 6 years of age, objective physiologic assessment is limited in the clinical care of infants and children less than 6 years old, due to the challenges of measuring lung function in this age range. Ongoing research in lung function testing in infants, toddlers, and preschoolers has resulted in techniques that show promise as safe, feasible, and potentially clinically useful tests. Official American Thoracic Society workshops were convened in 2009 and 2010 to review six lung function tests based on a comprehensive review of the literature (infant raised-volume rapid thoracic compression and plethysmography, preschool spirometry, specific airway resistance, forced oscillation, the interrupter technique, and multiple-breath washout). In these proceedings, the current state of the art for each of these tests is reviewed as it applies to the clinical management of infants and children under 6 years of age with cystic fibrosis, bronchopulmonary dysplasia, and recurrent wheeze, using a standardized format that allows easy comparison between the measures. Although insufficient evidence exists to recommend incorporation of these tests into the routine diagnostic evaluation and clinical monitoring of infants and young children with cystic fibrosis, bronchopulmonary dysplasia, or recurrent wheeze, they may be valuable tools with which to address specific concerns, such as ongoing symptoms or monitoring response to treatment, and as outcome measures in clinical research studies.

Quality indicators for high acuity pediatric conditions

OBJECTIVE

Identifying gaps in care and improving outcomes for severely ill children requires the development of evidence-based performance measures. We used a systematic process involving multiple stakeholders to identify and develop evidence-based quality indicators for high acuity pediatric conditions relevant to any emergency department (ED) setting where children are seen.

METHODS

A prioritized list of clinical conditions was selected by an advisory panel. A systematic review of the literature was conducted to identify existing indicators, as well as guidelines and evidence that could be used to inform the creation of new indicators. A multiphase, Rand-modified Delphi method consisting of anonymous questionnaires and a face-to-face meeting of an expert panel was used for indicator selection. Measure specifications and evidence grading were created for each indicator, and the feasibility and reliability of measurement was assessed in a tertiary care pediatric ED.

RESULTS

The conditions selected for indicator development were diabetic ketoacidosis, status asthmaticus, anaphylaxis, status epilepticus, severe head injury, and sepsis. The majority of the 62 selected indicators reflect ED processes (84%) with few indicators reflecting structures (11%) or outcomes (5%). Thirty-seven percent (n = 23) of the selected indicators are based on moderate or high quality evidence. Data were available and interrater reliability acceptable for the majority of indicators.

CONCLUSIONS

A systematic process involving multiple stakeholders was used to develop evidence-based quality indicators for high acuity pediatric conditions. Future work will test the reliability and feasibility of data collection on these indicators across the spectrum of ED settings that provide care for children.

Development and pretesting of an electronic learning module to train health care professionals on the use of the Pediatric Respiratory Assessment Measure to assess acute asthma severity

BACKGROUND

Severity-specific guidelines based on the Pediatric Respiratory Assessment Measure (PRAM), a validated clinical score, reduce pediatric asthma hospitalization rates.

OBJECTIVE

To develop, pretest the educational value of and revise an electronic learning module to train health care professionals on the use of the PRAM.

METHODS

The respiratory efforts of 32 children with acute asthma were videotaped and pulmonary auscultation was recorded. A pilot module, composed of a tutorial and 18 clinical cases, was developed in French and English. Health care professionals completed the module and provided feedback. The performance of participants, case quality and difficulty, and learning curve were assessed using the Rasch test; quantitative and qualitative feedback served to revise the module.

RESULTS

Seventy-two participants (19 physicians, 22 nurses, four respiratory therapists and 27 health care trainees) with a balanced distribution across self-declared expertise (26% beginner, 35% competent and 39% expert) were included. The accuracy of experts was superior to beginners (OR 1.79, 1.15 and 2.79, respectively). Overall performance significantly improved between the first and latter half of cases (P<0.001). Participants assessed the module to be clear (96%), relevant (98%), realistic (94%) and useful (99%) to learn the PRAM. The qualitative⁄quantitative analysis led to the deletion of three cases, modification of remaining cases to further enhance quality and reordering within three levels of difficulty.

DISCUSSION

Using rigorous educational methods, an electronic module was developed to teach health care professionals on use of the PRAM score. Using the back-translation technique, both French and English versions were developed and validated simultaneously. The pilot module comprised a tutorial and three case-scenario sections, and was tested on a target audience of physicians, nurses, respiratory therapists and medical trainees.

CONCLUSION

The final electronic learning module met the clarity and quality requirements of a good teaching tool, with a demonstrated learning effect and high appreciation by health care professionals. Available in French and English, it is offered to facilitate implementation of PRAM-based acute pediatric asthma guidelines.

Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children

BACKGROUND

There are several treatment options for managing acute asthma exacerbations (sustained worsening of symptoms that do not subside with regular treatment and require a change in management). Guidelines advocate the use of inhaled short acting beta2-agonists (SABAs) in children experiencing an asthma exacerbation. Anticholinergic agents, such as ipratropium bromide and atropine sulfate, have a slower onset of action and weaker bronchodilating effect, but may specifically relieve cholinergic bronchomotor tone and decrease mucosal edema and secretions. Therefore, the combination of inhaled anticholinergics with SABAs may yield enhanced and prolonged bronchodilation.

OBJECTIVES

To determine whether the addition of inhaled anticholinergics to SABAs provides clinical improvement and affects the incidence of adverse effects in children with acute asthma exacerbations.

SEARCH METHODS

We searched MEDLINE (1966 to April 2000), EMBASE (1980 to April 2000), CINAHL (1982 to April 2000) and reference lists of studies of previous versions of this review. We also contacted drug manufacturers and trialists. For the 2012 review update, we undertook an 'all years' search of the Cochrane Airways Group's register on the 18 April 2012.

SELECTION CRITERIA

Randomized parallel trials comparing the combination of inhaled anticholinergics and SABAs with SABAs alone in children (aged 18 months to 18 years) with an acute asthma exacerbation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We used the GRADE rating system to assess the quality of evidence for our primary outcome (hospital admission).

MAIN RESULTS

Twenty trials met the review eligibility criteria, generated 24 study comparisons and comprised 2697 randomised children aged one to 18 years, presenting predominantly with moderate or severe exacerbations. Most studies involved both preschool-aged children and school-aged children; three studies also included a small proportion of infants less than 18 months of age. Nine trials (45%) were at a low risk of bias. Most trials used a fixed-dose protocol of three doses of 250 mcg or two doses of 500 mcg of nebulized ipratropium bromide in combination with a SABA over 30 to 90 minutes while three trials used a single dose and two used a flexible-dose protocol according to the need for SABA.The addition of an anticholinergic to a SABA significantly reduced the risk of hospital admission (risk ratio (RR) 0.73; 95% confidence interval (CI) 0.63 to 0.85; 15 studies, 2497 children, high-quality evidence). In the group receiving only SABAs, 23 out of 100 children with acute asthma were admitted to hospital compared with 17 (95% CI 15 to 20) out of 100 children treated with SABAs plus anticholinergics. This represents an overall number needed to treat for an additional beneficial outcome (NNTB) of 16 (95% CI 12 to 29).Trends towards a greater effect with increased treatment intensity and with increased asthma severity were observed, but did not reach statistical significance. There was no effect modification due to concomitant use of oral corticosteroids and the effect of age could not be explored. However, exclusion of the one trial that included infants (< 18 months) and contributed data to the main outcome, did not affect the results. Statistically significant group differences favoring anticholinergic use were observed for lung function, clinical score at 120 minutes, oxygen saturation at 60 minutes, and the need for repeat use of bronchodilators prior to discharge from the emergency department. No significant group difference was seen in relapse rates.Fewer children treated with anticholinergics plus SABA reported nausea and tremor compared with SABA alone; no significant group difference was observed for vomiting.

AUTHORS' CONCLUSIONS

Children with an asthma exacerbation experience a lower risk of admission to hospital if they are treated with the combination of inhaled SABAs plus anticholinergic versus SABA alone. They also experience a greater improvement in lung function and less risk of nausea and tremor. Within this group, the findings suggested, but did not prove, the possibility of an effect modification, where intensity of anticholinergic treatment and asthma severity, could be associated with greater benefit.Further research is required to identify the characteristics of children that may benefit from anticholinergic use (e.g. age and asthma severity including mild exacerbation and impending respiratory failure) and the treatment modalities (dose, intensity, and duration) associated with most benefit from anticholinergic use better.

Comparing predictions made by a prediction model, clinical score, and physicians: pediatric asthma exacerbations in the emergency department

BACKGROUND

Asthma exacerbations are one of the most common medical reasons for children to be brought to the hospital emergency department (ED). Various prediction models have been proposed to support diagnosis of exacerbations and evaluation of their severity.

OBJECTIVES

First, to evaluate prediction models constructed from data using machine learning techniques and to select the best performing model. Second, to compare predictions from the selected model with predictions from the Pediatric Respiratory Assessment Measure (PRAM) score, and predictions made by ED physicians.

DESIGN

A two-phase study conducted in the ED of an academic pediatric hospital. In phase 1 data collected prospectively using paper forms was used to construct and evaluate five prediction models, and the best performing model was selected. In phase 2 data collected prospectively using a mobile system was used to compare the predictions of the selected prediction model with those from PRAM and ED physicians.

MEASUREMENTS

Area under the receiver operating characteristic curve and accuracy in phase 1; accuracy, sensitivity, specificity, positive and negative predictive values in phase 2.

RESULTS

In phase 1 prediction models were derived from a data set of 240 patients and evaluated using 10-fold cross validation. A naive Bayes (NB) model demonstrated the best performance and it was selected for phase 2. Evaluation in phase 2 was conducted on data from 82 patients. Predictions made by the NB model were less accurate than the PRAM score and physicians (accuracy of 70.7%, 73.2% and 78.0% respectively), however, according to McNemar's test it is not possible to conclude that the differences between predictions are statistically significant.

CONCLUSION

Both the PRAM score and the NB model were less accurate than physicians. The NB model can handle incomplete patient data and as such may complement the PRAM score. However, it requires further research to improve its accuracy.

A simplified severity score for acute asthma exacerbation

BACKGROUND

To evaluate a simplified severity score designed to facilitate decision making in the Emergency Department (ED) regarding hospital admission of young adult patients with acute asthma exacerbation (AAE).

METHODS

All AAE-related ED encounters during two calendar years of patients aged 17-35 years were retrospectively classified as "mild", "moderate" or "severe", according to vital and readily available signs and symptoms, including pulse rate, presence of respiratory wheezes, rales or prolonged expirium, oxygen saturation, and the use of accessory muscles, measured upon arrival to the ED. All medical records of ED and hospital admissions were reviewed for treatment and outcomes.

RESULTS

During the study period, 723 AAE-related ED encounters were recorded among 551 asthma patients. Of them, 35.0% were classified as "mild", 37.9% "moderate" and 27.1% "severe". For increasing levels of AAE severity, hospital admission rate increased (11.5%, 42.0%, 61.2%, respectively, p < 0.001). Adjusting for age and sex, odds ratios for hospitalization were 12.2 (95% CI: 7.5-19.9) and 5.6 (95% CI: 3.5-8.9) for the "severe" and "moderate" categories, respectively, compared to the "mild" category. "Mild" asthma patients also had shorter length of hospital stay and none required mechanical ventilation or died during hospitalization.

CONCLUSION

The simplified asthma severity score requires no additional tests or costs in the ED, and could facilitate the decision of whether to hospitalize or discharge adult AAE patients. Prospective validation of this tool is needed.

Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial

BACKGROUND

The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for 'point of care' management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways.

DESIGN/METHODS

We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma--the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis--the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits.

DISCUSSION

This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01815710.

Managing the paediatric patient with an acute asthma exacerbation

Children with acute asthma exacerbations frequently present to an emergency department with signs of respiratory distress. The most severe episodes are potentially life-threatening. Effective treatment depends on the accurate and rapid assessment of disease severity at presentation. This statement addresses the assessment, management and disposition of paediatric patients with a known diagnosis of asthma who present with an acute asthma exacerbation, especially preschoolers at high risk for persistent asthma. Guidance includes the assessment of asthma severity, treatment considerations, proper discharge planning, follow-up, and prescription for inhaled corticosteroids to prevent exacerbation and decrease chronic morbidity.

Spirometry and PRAM severity score changes during pediatric acute asthma exacerbation treatment in a pediatric emergency department

OBJECTIVES

To examine the time-dependent changes of spirometry (percent-predicted forced expiratory volume in 1 second [%FEV(1)]) and the Pediatric Respiratory Assessment Measure (PRAM) during the treatment of acute asthma exacerbations.

STUDY DESIGN

We conducted a prospective study of participants aged 5-17 years with acute asthma exacerbations managed in a Pediatric Emergency Department. %FEV(1) and the PRAM were recorded pretreatment and at 2 and 4 hours. We examined responses at 2 and 4 hours following treatment and assessed whether the changes of %FEV(1) and of the PRAM differed during the first and the second 2-hour treatment periods.

RESULTS

Among 503 participants, median [interquartile range, IQR] age was 8.8 [6.9, 11.4], 61% were male, and 63% were African-American. There was significant mean change of %FEV(1) during the first (+15.4%; 95% CI 13.7 to 17.1; p < .0001), but not during the second (+1.5%; 95% CI -0.8 to 3.8; p = .21), 2-hour period and of the PRAM during the first (-2.1 points; 95% CI -2.3 to -1.9; p < .0001) and the second (-1.0 point; 95% CI -1.3 to -0.7; p < .0001) 2-hour periods.

CONCLUSIONS

Most improvement of lung function and clinical severity occur in the first 2 hours of treatment. Among pediatric patients with acute asthma exacerbations, the PRAM detects significant and clinically meaningful change of severity during the second 2-hour treatment, whereas spirometry does not. This suggests that spirometry and clinical severity scores do not have similar trajectories and that clinical severity scores may be more sensitive to clinical change of acute asthma severity than spirometry.

Predicting hospitalization in children with acute asthma

BACKGROUND

Acute asthma is one of the most common medical emergencies in children. Appropriate assessment/treatment and early identification of factors that predict hospitalization are critical for the effective utilization of emergency services.

OBJECTIVE

To identify risk factors that predict hospitalization and to compare the concordance of the Modified Pulmonary Index Score (MPIS) with the Global Initiative for Asthma (GINA) guideline criteria in terms of attack severity.

METHODS

The study population was composed of children aged 5-18 years who presented to the Emergency Departments (ED) of the tertiary reference centers of the country within a period of 3 months. Patients were evaluated at the initial presentation and the 1(st) and 4(th) hours.

RESULTS

Of the 304 patients (median age: 8.0 years [interquartile range: 6.5-9.7]), 51.3% and 19.4% required oral corticosteroids (OCS) and hospitalization, respectively. Attack severity and MPIS were found as predicting factors for hospitalization, but none of the demographic characteristics collected predicted OCS use or hospitalization. Hospitalization status at the 1(st) hour with moderate/severe attack severity showed a sensitivity of 44.1%, specificity of 82.9%, positive predictive value of 38.2%, and negative predictive value of 86.0%; for MPIS ≥ 5, these values were 42.4%, 85.3%, 41.0%, and 86.0%, respectively. Concordance in prediction of hospitalization between the MPIS and the GINA guideline was found to be moderate at the 1(st) hour (κ = 0.577).

CONCLUSION

Attack severity is a predictive factor for hospitalization in children with acute asthma. Determining attack severity with MPIS and a cut-off value ≥ 5 at the 1(st) hour may help physicians in EDs. Having fewer variables and the ability to calculate a numeric value with MPIS makes it an easy and useful tool in clinical practice.

The Saudi initiative for asthma - 2012 update: Guidelines for the diagnosis and management of asthma in adults and children

This an updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have updated guidelines, which are simple to understand and easy to use by non-asthma specialists, including primary care and general practice physicians. This new version includes updates of acute and chronic asthma management, with more emphasis on the use of Asthma Control Test in the management of asthma, and a new section on "difficult-to-treat asthma." Further, the section on asthma in children was re-written to cover different aspects in this age group. The SINA panel is a group of Saudi experts with well-respected academic backgrounds and experience in the field of asthma. The guidelines are formatted based on the available evidence, local literature, and the current situation in Saudi Arabia. There was an emphasis on patient-doctor partnership in the management that also includes a self-management plan. The approach adopted by the SINA group is mainly based on disease control as it is the ultimate goal of treatment.

Correlation of a unique "Los Angeles" phonospirometry technique with peak expiratory flows in children with asthma

BACKGROUND

Measurement of peak expiratory flow (PEF) is recommended as part of the assessment of patients with asthma. However, there are multiple barriers in the use of PEF, even for older pediatric patients.

OBJECTIVE

Phonospirometry, as measured by the Los Angeles (LA) technique, was assessed and compared with standard PEF measurements in patients with asymptomatic and symptomatic asthma.

METHODS

A convenience sample of patients with asthma aged 8-17 years was enrolled from visits in the Allergy/Immunology Clinic and in the Emergency Department of Children's Hospital Los Angeles. The phonospirometry technique was demonstrated, and the length of time the patient repeated the syllable "lah" continuously with the same breath was measured. After a brief interval of time to recover, the patient performed conventional PEF measurement.

RESULTS

Using the first observation for each patient in our study, the Pearson correlation coefficient between phonospirometry and PEF was r = 0.67, p = .0016 for asymptomatic asthma patients and r = 0.77, p < .0001 for symptomatic asthma patients. Analysis of the first and last measurements of the symptomatic asthma patients who had multiple measurements revealed a Pearson correlation coefficient between phonospirometry and PEF at first measurement r = 0.69, p = .0008 and at the last measurement r = 0.76, p < .0001.

CONCLUSIONS

Using the LA technique, phonospirometry was shown to have a linear correlation with PEF in pediatric patients with asymptomatic and symptomatic asthma. It is simple and easily reproducible, as well as cross-cultural. This novel technique shows promise to aid the assessment of patients with acute asthma exacerbations.

Advanced nursing directives: integrating validated clinical scoring systems into nursing care in the pediatric emergency department

In an effort to improve the quality and flow of care provided to children presenting to the emergency department the implementation of nurse-initiated protocols is on the rise. We review the current literature on nurse-initiated protocols, validated emergency department clinical scoring systems, and the merging of the two to create Advanced Nursing Directives (ANDs). The process of developing a clinical pathway for children presenting to our pediatric emergency department (PED) with suspected appendicitis will be used to demonstrate the successful integration of validated clinical scoring systems into practice through the use of Advanced Nursing Directives. Finally, examples of 2 other Advanced Nursing Directives for common clinical PED presentations will be provided.

Magnesium use in asthma pharmacotherapy: a Pediatric Emergency Research Canada study

OBJECTIVES

To examine the use of intravenous magnesium in Canadian pediatric emergency departments (EDs) in children requiring hospitalization for acute asthma and association of administration of frequent albuterol/ipratropium and timely corticosteroids with hospitalization.

METHODS

Retrospective medical record review at 6 EDs of otherwise healthy children 2 to 17 years of age with acute asthma. Data were extracted on history, disease severity, and timing of ED stabilization treatments with inhaled albuterol, ipratropium, corticosteroids, and magnesium. Primary outcome was the proportion of hospitalized children given magnesium in the ED. Secondary outcome was the ED use of "intensive therapy" in hospitalized children, defined as 3 albuterol inhalations with ipratropium and corticosteroids within 1 hour of triage.

RESULTS

A total of 19 (12.3%) of 154 hospitalized children received magnesium (95% confidence interval 7.1, 17.5) versus 2 of 962 discharged patients. Children given magnesium were more likely to have been previously admitted to ICU (odds ratio [OR] 11.2), hospitalized within the past year (OR 3.8), received corticosteroids before arrival (OR 4.0), presented with severe exacerbation (OR 6.1), and to have been treated at 1 particular center (OR 14.9). Forty-two (53%) of 90 hospitalized children were not given "intensive therapy." Children receiving "intensive therapy" were more likely to present with severe disease to EDs by using asthma guidelines (ORs 8.9, 3.0). Differences in the frequencies of all stabilization treatments were significant across centers.

CONCLUSIONS

Magnesium is used infrequently in Canadian pediatric EDs in acute asthma requiring hospitalization. Many of these children also do not receive frequent albuterol and ipratropium, or early corticosteroids. Significant variability in the use of these interventions was detected.

Common pediatric respiratory emergencies

Pediatric respiratory illnesses are a huge burden to emergency departments worldwide. This article reviews the latest evidence in the epidemiology, assessment, management, and disposition of children presenting to the emergency department with asthma, croup, bronchiolitis, and pneumonia.

Asthma outcomes: exacerbations

BACKGROUND

The goals of asthma treatment include preventing recurrent exacerbations. Yet there is no consensus about the terminology for describing or defining "exacerbation" or about how to characterize an episode's severity.

OBJECTIVE

National Institutes of Health institutes and other federal agencies convened an expert group to propose how asthma exacerbation should be assessed as a standardized asthma outcome in future asthma clinical research studies.

METHODS

We used comprehensive literature reviews and expert opinion to compile a list of asthma exacerbation outcomes and classified them as either core (required in future studies), supplemental (used according to study aims and standardized), or emerging (requiring validation and standardization). This work was discussed at a National Institutes of Health-organized workshop in March 2010 and finalized in September 2011.

RESULTS

No dominant definition of "exacerbation" was found. The most widely used definitions included 3 components, all related to treatment, rather than symptoms: (1) systemic use of corticosteroids, (2) asthma-specific emergency department visits or hospitalizations, and (3) use of short-acting β-agonists as quick-relief (sometimes referred to as "rescue" or "reliever") medications.

CONCLUSIONS

The working group participants propose that the definition of "asthma exacerbation" be "a worsening of asthma requiring the use of systemic corticosteroids to prevent a serious outcome." As core outcomes, they propose inclusion and separate reporting of several essential variables of an exacerbation. Furthermore, they propose the development of a standardized, component-based definition of "exacerbation" with clear thresholds of severity for each component.

Triage nurse initiation of corticosteroids in pediatric asthma is associated with improved emergency department efficiency

OBJECTIVE

To assess the effectiveness of nurse-initiated administration of oral corticosteroids before physician assessment in moderate to severe acute asthma exacerbations in the pediatric ED.

METHODS

A time-series controlled trial evaluated nurse initiation of treatment with steroids before physician assessment in children with Pediatric Respiratory Assessment Measure score ≥4. One-to-one periods (physician-initiated and nurse-initiated) were analyzed from September 2009 through May 2010. In both phases, triage nurses initiated bronchodilator therapy before physician assessment, per Pediatric Respiratory Assessment Measure score. We reviewed charts of 644 consecutive children aged 2 to 17 years for the following outcomes: admission rate; times to clinical improvement, steroid receipt, mild status, and discharge; and rate of return ED visit and subsequent admission.

RESULTS

Nurse-initiated phase children improved earlier compared to physician-initiated phase (median difference: 24 minutes; 95% confidence interval [CI]: 1-50; P = .04). Admission was less likely if children received steroids at triage (odds ratio = 0.56; 95% CI: 0.36-0.87). Efficiency gains were made in time to steroid receipt (median difference: 44 minutes; 95% CI: 39-50; P < .001), time to mild status (median difference: 51 minutes; 95% CI: 17-84; P = .04), and time to discharge (median difference: 44 minutes; 95% CI: 17-68; P = .02). No differences were found in return visit rate or subsequent admission.

CONCLUSIONS

Triage nurse initiation of oral corticosteroid before physician assessment was associated with reduced times to clinical improvement and discharge, and reduced admission rates in children presenting with moderate to severe acute asthma exacerbations.

Early administration of systemic corticosteroids reduces hospital admission rates for children with moderate and severe asthma exacerbation

STUDY OBJECTIVE

The variable effectiveness of clinical asthma pathways to reduce hospital admissions may be explained in part by the timing of systemic corticosteroid administration. We examine the effect of early (within 60 minutes [SD 15 minutes] of triage) versus delayed (>75 minutes) administration of systemic corticosteroids on health outcomes.

METHODS

We conducted a prospective observational cohort of children aged 2 to 17 years presenting to the emergency department with moderate or severe asthma, defined as a Pediatric Respiratory Assessment Measure (PRAM) score of 5 to 12. The outcomes were hospital admission, relapse, and length of active treatment; they were analyzed with multivariate logistic and linear regressions adjusted for covariates and potential confounders.

RESULTS

Among the 406 eligible children, 88% had moderate asthma; 22%, severe asthma. The median age was 4 years (interquartile range 3 to 8 years); 64% were male patients. Fifty percent of patients received systemic corticosteroids early; in 33%, it was delayed; 17% of children failed to receive any. Overall, 36% of patients were admitted to the hospital. Compared with delayed administration, early administration reduced the odds of admission by 0.4 (95% confidence interval 0.2 to 0.7) and the length of active treatment by 0.7 hours (95% confidence interval -1.3 to -0.8 hours), with no significant effect on relapse. Delayed administration was positively associated with triage priority and negatively with PRAM score.

CONCLUSION

In this study of children with moderate or severe asthma, administration of systemic corticosteroids within 75 minutes of triage decreased hospital admission rate and length of active treatment, suggesting that early administration of systemic corticosteroids may allow for optimal effectiveness.

The RAD score: a simple acute asthma severity score compares favorably to more complex scores

BACKGROUND

Acute asthma severity scores facilitate assessment and implementation of timely and appropriate therapy for pediatric patients but are complex and challenging for clinicians to use at the bedside.

OBJECTIVE

To assess whether a simple, bedside acute asthma severity score comprising 3 standard clinical measures performs as well as more comprehensive asthma scores.

METHODS

We prospectively enrolled participants 5 to 17 years of age with acute asthma exacerbations. We recorded 3 asthma scores at baseline and after 2 hours of treatment: the Pediatric Asthma Severity Score (PASS), the Pediatric Respiratory Assessment Measure (PRAM), and the RAD score (Respiratory rate; Accessory muscle use; Decreased breath sounds). We assessed each score for criterion validity in predicting baseline percent forced expiratory volume in 1 second (%FEV(1)) and for responsiveness in predicting change of %FEV(1) after 2 hours of treatment using multiple linear regression models adjusted for age, race, sex, and Global Initiative for Asthma chronic control.

RESULTS

Of 536 participants included for analyses, median age was 8.8 years, 60% were male, and 58% were African American. The 3 acute asthma scores demonstrated similar criterion validity to explain variation of baseline %FEV(1) (R(2): 0.434 [PASS]; 0.462 [PRAM]; 0.426 [RAD]), but none demonstrated clinically significant responsiveness to change in %FEV(1) (R(2): 0.109 [PASS]; 0.106 [PRAM]; 0.139 [RAD]).

CONCLUSIONS

The RAD score, comprising 3 routinely measured bedside clinical parameters, is a simple and easily used instrument for assessing the severity of an acute asthma exacerbation and has comparable criterion validity and improved responsiveness when compared with 2 more complex acute asthma scores.

The Acute Asthma Severity Assessment Protocol (AASAP) study: objectives and methods of a study to develop an acute asthma clinical prediction rule

Acute asthma exacerbations are one of the most common reasons for paediatric emergency department visits and hospitalisations, and a relapse frequently necessitates repeat urgent care. While care plans exist, there are no acute asthma prediction rules (APRs) to assess severity and predict outcome. The primary objective of the Acute Asthma Severity Assessment Protocol study is to develop a multivariable APR for acute asthma exacerbations in paediatric patients. A prospective, convenience sample of paediatric patients aged 5-17 years with acute asthma exacerbations who present to an urban, academic, tertiary paediatric emergency department was enrolled. The study protocol and data analysis plan conform to accepted biostatistical and clinical standards for clinical prediction rule development. Modelling of the APR will be performed once the entire sample size of 1500 has accrued. It is anticipated that the APR will improve resource utilisation in the emergency department, aid in standardisation of disease assessment and allow physician and non-physician providers to participate in earlier objective decision making. The objective of this report is to describe the study objectives and detailed methodology of the Acute Asthma Severity Assessment Protocol study.

Focusing the focus group: impact of the awareness of major factors contributing to non-adherence to acute paediatric asthma guidelines

RATIONALE

The administration of oral corticosteroids within the first hour in the emergency department is associated with reduced hospitalization rates in children with moderate and severe asthma, yet less than half of patients benefit from this recommendation. To ensure patients receive recommended treatment, a clear understanding of what is causing suboptimal care management is needed. The assessment of barriers and solutions to optimal care is often done without a thorough examination of the factors associated with non-adherence.

OBJECTIVE

To evaluate whether knowledge of factors associated with delayed administration of systemic corticosteroids modifies the focus and prioritization of barriers and solutions identified by focus groups.

METHODS

We conducted two parallel focus groups of emergency health care professionals - one group informed and the other non-informed of key factors. Both groups received a presentation on the acute asthma guidelines, the evidence supporting its recommendations, and current practice. In addition, the informed group was provided with the factors associated and not associated with delayed administration. The groups were given 20 minutes to discuss barriers and solutions, with 5 minutes each for voting for the main barriers and solutions. Group difference in the misdirection of discussion was measured as time spent discussing barriers that were shown not to be associated with systemic corticosteroids. Prioritization of barriers and solutions was based on group endorsement.

RESULTS

The non-informed group spent more time discussing barriers not associated with delayed administration (15 vs. 2 minutes, P = 0.05). Although the non-informed group proposed more solutions, most were to overcome barriers not associated with delayed administration. Of the main barriers and solutions identified by each group, only one barrier and solution were similar between the two groups: emergency department overcrowding and administrating corticosteroids at triage.

CONCLUSION

The awareness of objective factors of non-adherence enabled a more directed discussion on relevant barriers and solutions, affecting prioritization of each. The administration of oral corticosteroids at triage appears to be the best solution to overcome delayed administration.

Endpoints in respiratory diseases

A wide range of outcome measures or endpoints has been used in clinical trials to assess the effects of treatments in paediatric respiratory diseases. This can make it difficult to compare treatment outcomes from different trials and also to understand whether new treatments offer a real clinical benefit for patients. Clinical trials in respiratory diseases evaluate three types of endpoints: subjective, objective and health-related outcomes. The ideal endpoint in a clinical trial needs to be accurate, precise and reliable. Ideally, the endpoint would also be measured with minimal risk and across all ages, easy to perform, and be inexpensive. As for any other disease, endpoints for respiratory diseases must be viewed in the context of the important distinction between clinical endpoints and surrogate endpoints. The association between surrogate endpoints and clinical endpoints must be clearly defined for any disease in order for them to be meaningful as outcome measures. The most common endpoints which are used in paediatric trials in respiratory diseases are discussed. For practical purposes, diseases have been separated into acute (bronchiolitis, acute viral-wheeze, acute asthma and croup) and chronic (asthma and cystic fibrosis). Further development of endpoints will enable clinical trials in children with respiratory diseases with the main objective of improving prognosis and safety.

North American practice patterns of intravenous magnesium therapy in severe acute asthma in children

OBJECTIVES

Although intravenous (IV) magnesium (Mg) can decrease hospitalizations in children with severe acute asthma, its use is often limited to resistant disease, and disposition may be determined prior to its use. Since knowledge about practice patterns of IV Mg would enhance knowledge translation and guide future research, we surveyed pediatric emergency physicians with interest in clinical research to determine the frequency, indications, adverse events, and barriers to use of IV Mg in children with severe acute asthma.

METHODS

A cross-sectional online survey of two national pediatric emergency physician associations in Canada and the United States was conducted using a modified Dillman technique.

RESULTS

Response rates were 124 of 180 (69%) in Canada and 75 of 108 (69%) in the United States. Although 88% of participants report knowing that Mg is effective, only 14 of 199 (7%) give it to prevent hospitalizations and 142 of 199 (71%) give it to prevent admissions to the intensive care unit (ICU). Thirty-eight percent of respondents use Mg in < 5% of stable children with severe acute asthma, while 79% use it in 50% or more of the ICU candidates with concern about impending respiratory failure. Seventy-nine percent of the participants report that < 5% of their patients given Mg are discharged home from the ED. Twenty-four percent of respondents who administer Mg have encountered associated severe hypotension requiring therapy, and 2% have witnessed-related apnea. Factors affecting Mg use include concern about side effects expressed by 24% of physicians and a belief that IV therapy is not necessary, expressed by 31%.

CONCLUSIONS

Intravenous Mg appears to be uncommonly used in stable children with severe acute asthma and does not frequently play a role in reducing hospitalizations. Further research to justify its enhanced use and to better establish its true adverse effect profile is indicated.

Prospective evaluation of two clinical scores for acute asthma in children 18 months to 7 years of age

OBJECTIVES

The objective was to evaluate the discriminatory ability of two clinical asthma scores, the Preschool Respiratory Assessment Measure (PRAM) and the Pediatric Asthma Severity Score (PASS), during an asthma exacerbation.

METHODS

This was a prospective cohort study in an academic pediatric emergency department (ED; 60,000 visits/year) conducted from March 2006 to October 2007. All patients 18 months to 7 years of age who presented for an asthma exacerbation were eligible. The primary outcome was a length of stay (LOS) of >6 hours in the ED or admission to the hospital. Clinical findings and components of the PRAM and the PASS were assessed by a respiratory therapist (RT) at the start of the ED visit and after 90 minutes of treatment.

RESULTS

During the study period, 3,845 patients were seen in the ED for an asthma exacerbation. Of these, 291 were approached to participate, and eight refused. Moderate levels of discrimination were found between a LOS of >6 hours and/or admission and PRAM (area under the receiver-operating characteristic curve [AUC] = 0.69, 95% confidence interval [CI] = 0.59 to 0.79) and PASS (AUC = 0.70, 95% CI = 0.60 to 0.80) as calculated at the start of the ED visit. Significant similar correlations were seen between the physician's judgment of severity and PRAM (r = 0.54, 95% CI = 0.42 to 0.65) and PASS (r = 0.55, 95% CI = 0.43 to 0.65).

CONCLUSIONS

The PRAM and PASS clinical asthma scores appear to be measures of asthma severity in children with discriminative properties.

Oral prednisolone for preschool children with acute virus-induced wheezing

BACKGROUND

Attacks of wheezing induced by upper respiratory viral infections are common in preschool children between the ages of 10 months and 6 years. A short course of oral prednisolone is widely used to treat preschool children with wheezing who present to a hospital, but there is conflicting evidence regarding its efficacy in this age group.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial comparing a 5-day course of oral prednisolone (10 mg once a day for children 10 to 24 months of age and 20 mg once a day for older children) with placebo in 700 children between the ages of 10 months and 60 months. The children presented to three hospitals in England with an attack of wheezing associated with a viral infection; 687 children were included in the intention-to-treat analysis (343 in the prednisolone group and 344 in the placebo group). The primary outcome was the duration of hospitalization. Secondary outcomes were the score on the Preschool Respiratory Assessment Measure, albuterol use, and a 7-day symptom score.

RESULTS

There was no significant difference in the duration of hospitalization between the placebo group and the prednisolone group (13.9 hours vs. 11.0 hours; ratio of geometric means, 0.90; 95% confidence interval, 0.77 to 1.05) or in the interval between hospital admission and signoff for discharge by a physician. In addition, there was no significant difference between the two study groups for any of the secondary outcomes or for the number of adverse events.

CONCLUSIONS

In preschool children presenting to a hospital with mild-to-moderate wheezing associated with a viral infection, oral prednisolone was not superior to placebo. (Current Controlled Trials number, ISRCTN58363576.)

The Pediatric Respiratory Assessment Measure: a valid clinical score for assessing acute asthma severity from toddlers to teenagers

OBJECTIVE

To determine the performance characteristics of the Preschool Respiratory Assessment Measure (PRAM) in preschool and school-aged children with acute asthma.

STUDY DESIGN

In a prospective cohort study, we examined the validity, responsiveness, and reliability of the PRAM in children aged 2 to 17 years with acute asthma. The study involved more than 100 nurses and physicians who recorded the PRAM on triage, after initial bronchodilation, and at disposition. Predictive validity and responsiveness were examined using disposition as outcome.

RESULTS

The PRAM was recorded in 81% (n = 782) of patients at triage. The PRAM at triage and after initial bronchodilation showed a strong association with admission (r = 0.4 and 0.5, respectively; P < .0001), thus supporting its ability to distinguish across severity levels. The responsiveness coefficient of 0.7 indicated good ability to identify change after bronchodilation. The PRAM showed good internal consistency (Cronbach alpha = 0.71) and inter-rater reliability (r = 0.78) for all patients and across all age groups.

CONCLUSIONS

Good performance characteristics were observed in all age groups, making the PRAM an attractive score for assessing asthma severity and response to treatment.

Principles of managing children with asthma in the emergency department

INTRODUCTION: Paediatric asthma exacerbations comprise a significant portion of emergency department (ED) visits and hospitalizations. Recognition of diagnostic symptoms and signs, and timely use of appropriate medications may reduce the need of hospitalizations and the impact of this disease on the lives of children and their families. OBJECTIVE: To review the pathophysiology of asthma, the current recommendations for conventional medical treatment in the ED, the controversies surrounding adjunct therapies, and the importance of discharge planning and follow-up. CONCLUSIONS: Paediatric asthma exacerbations may be successfully treated in the ED with the use of appropriate inhaled and systemic medications.

Lung function in preschool children: applications in clinical and epidemiological research

During recent years there has been significant development of pulmonary function tests for use in preschool children. A range of tests including multiple inert gas washout, plethysmography, spirometry, interrupter resistance and impulse oscillometry have been shown to be feasible and to be able to identify diminished lung function in children with lung disease such as asthma or cystic fibrosis. An overview of these applications in clinical and epidemiological research is given. Future applications to investigate the longer term effect of preterm delivery, intra-uterine growth retardation, smoking and assessing the response to therapeutic intervention would strengthen the scientific basis for the prevention and treatment of respiratory disease in early life.

Intravenous aminophylline for acute severe asthma in children over two years receiving inhaled bronchodilators

BACKGROUND

Since the advent of inhaled beta2-agonists, anticholinergic agents and glucocorticoids, the role of aminophylline in paediatric acute asthma has become less clear. There remains some consensus that it is beneficial in children with acute severe asthma, receiving maximised therapy (oxygen, inhaled bronchodilators, and glucocorticoids).

OBJECTIVES

To determine if the addition of intravenous aminophylline produces a beneficial effect in children with acute severe asthma receiving conventional therapy.

SEARCH STRATEGY

The Cochrane Airways Group register of trials was used to identify relevant studies. The latest search was carried out in December 2004

SELECTION CRITERIA

Randomised-controlled trials comparing intravenous aminophylline with placebo in addition to usual care in children met the inclusion criteria.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies and extracted data. Disagreement in the selection of trials was resolved by consensus. Attempts were made to contact authors to verify accuracy of data.

MAIN RESULTS

Seven trials met the inclusion criteria (380 participants). Methodological quality was high. All studies recruited children with acute severe asthma and requiring hospital admission. Six studies sought participants who were unresponsive to nebulised short-acting beta-agonist and administered systemic steroids to study participants. In two studies where some children were able to perform spirometry, baseline FEV1 was between 35 and 45% predicted. The addition of aminophylline to steroids and beta2-agonist significantly improved FEV1% predicted over placebo at 6-8 hours, 12-18 hours and 24 hours. Aminophylline led to a greater improvement in PEF% predicted over placebo at 12-18 hours. There was no significant difference in length of hospital stay, symptoms, frequency of nebulsations and mechanical ventilation rates. There were insufficient data to permit aggregation for oxygenation and duration of supplemental oxygen therapy. Aminophylline led to a three-fold increase in the risk of vomiting. There was no significant difference between treatment groups with regard to hypokalaemia, headaches, tremour, seizures, arrhythmias and deaths.

AUTHORS' CONCLUSIONS

In children with a severe asthma exacerbation, the addition of intravenous aminophylline to beta2-agonists and glucocorticoids (with or without anticholinergics) improves lung function within 6 hours of treatment. However there is no apparent reduction in symptoms, number of nebulised treatment and length of hospital stay. There is insufficient evidence to assess the impact on oxygenation, PICU admission and mechanical ventilation. Aminophylline is associated with a significant increased risk of vomiting.

Asthma severity scores for preschoolers displayed weaknesses in reliability, validity, and responsiveness

OBJECTIVE

To evaluate the measurement properties of asthma severity scores for use in preschool children.

METHODS

A Medline search was used to identify published asthma severity scores for use in preschool children. The measurement properties of the scores (item development, reliability, validity, responsiveness, and usability) were evaluated using a published framework.

RESULTS

Ten asthma severity scores were identified, with 19 different clinical variables used as items. Interrater agreement was assessed by five scores. Only two scores--Clinical Asthma Score (CAS) and Respiratory Distress Assessment Index (RDAI)--reported good agreement based on weighted kappa-statistics (0.64-0.90). Construct validity was reported by the CAS, Clinical Asthma Evaluation Score (CAES), the Clinical Symptom Grading System (CSGS), and the Preschool Respiratory Assessment Measure (PRAM). Correlation coefficients between asthma severity scores and clinical measures (length of stay, drug dosing interval, O2 saturation, health professional assessment, PaO2, PaCO2) ranged from 0.47 to 0.70. Responsiveness was formally demonstrated for two scales (PRAM, CAS).

CONCLUSIONS

Most asthma severity scales for use in preschool children have been informally developed. Recently developed scores (CAS, PRAM) have more rigorously evaluated their measurement properties. Research is needed to directly compare the asthma severity scores developed for use in preschool children.