Factors associated with short-term clinical outcomes after acute treatment of asthma in a pediatric emergency department

A Randomized Controlled Study Addressing Dexamethasone Tolerability in the Treatment of Acute Asthma in Children: Mary Poppins on Trial!

AIM

Emesis of oral medications continues to be a problem in the management of acute pediatric asthma exacerbations; therefore, we set out to assess whether smaller volumes of oral dexamethasone resulted in better tolerability.

METHODS

Children aged 2-14 years, presenting to the emergency department with acute asthma exacerbation, were enrolled in this open, prospective randomized controlled trial. Participants received 0.3 mg/kg of dexamethasone in either its concentrated volume (10 mg/mL) or mixed with Ora Sweet (1 mg/mL). Tolerability was measured by vomiting within 45 minutes of receiving dexamethasone, with stratification, a priori, for prior vomiting.

RESULTS

430 participants were enrolled. 23/213 (11%) in the 10 mg/mL group vomited dexamethasone compared to 16/217 (7%) in the 1 mg/mL group (P = .29). 11/179 (6%) in the 10 mg/mL group vomited compared to 8/183 (3%) in the 1 mg/mL group (.61). For those 68 stratified with prior vomiting, 12/34 (35%) in the 10 mg/mL group vomited compared to 8/34 (24%) in the 1 mg/mL group (P = .43). None of these results were statistically different. Prior vomiting increased the risk of vomiting, regardless of the formulation given (P < .001).

CONCLUSIONS

Volume does not play a significant role in the tolerability of dexamethasone. Therefore, palatability should not be sacrificed for a smaller volume of dexamethasone to improve tolerability.

Oral Dexamethasone vs. Oral Prednisone for Children With Acute Asthma Exacerbations: A Systematic Review and Meta-Analysis

Background: This systematic review and meta-analysis was conducted to compare relapse rates and adverse effects with oral dexamethasone vs. oral prednisone for acute asthma exacerbations in pediatric patients. Methods: A computerized literature search of PubMed, Embase, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials) and Google scholar databases was carried out till 1st August 2019. Six Randomized controlled trials (RCTs) and 1 quasi-RCT were included. Dosage of dexamethasone and prednisone varied across studies. Studies were grouped based on the follow-up period and duration of dexamethasone administration. Results: There was no significant difference in the relapse rate between dexamethasone and prednisone at 1-5 days (RR 1.46, 95%CI 0.69-3.7, P = 0.32; I 2 = 0%) and 10-15 days of follow up (RR 1.16, 95%CI 0.80-1.68, P = 0.44; I 2 = 0%). Pooled analysis found no significant difference in relapse rates with 1-day (RR 1.15, 95%CI 0.68-1.95, P = 0.60; I 2 = 0%) and 2-day dosage of dexamethasone (RR 1.25, 95%CI 0.82-1.92, P = 0.30; I 2 = 0%) compared to prednisone. Hospital readmission rates after initial discharge were not significantly different between the two drugs (RR 1.49, 95%CI 0.56-4.01, P = 0.43; I 2 = 0%). Frequency of vomiting at ED (RR 0.21, 95%CI 0.05-0.96, P = 0.04; I 2 = 50%) and at home (RR 0.42, 95%CI 0.25-0.69, P = 0.0007; I 2 = 0%) was significantly higher with prednisone as compared to dexamethasone. Conclusion: While our results indicate that both dexamethasone and prednisone have similar relapse rates when used for acute asthmatic exacerbations, strong conclusions cannot be drawn due to paucity of large scale RCTs and limited quality of evidence. Dexamethasone is however associated with lower incidence of vomiting as compared to prednisone. Further homogenous RCTs are needed to provide robust evidence on this topic.

Repeated doses of salbutamol and aeroallergen sensitisation both increased salbutamol-induced hypoxia in children and adolescents with acute asthma

AIM

We aimed to identify the frequency, magnitude and risk factors of salbutamol-induced hypoxia in children with acute asthma.

METHODS

This study was conducted at Hacettepe University on children who presented to the paediatric allergy clinic or the paediatric emergency room with acute asthma between July 2014 and June 2015. Vital signs, pulse oximetry-defined oxygen saturation and modified pulmonary index scores were evaluated before and after the first, second and third doses of nebulised salbutamol and repeated one and 10 days later.

RESULTS

We included 304 patients (65.7% male) from median age of 5.3 years (range 1-18 years). Salbutamol-induced hypoxia was detected in 14.7%, 3.9% and 1.3%, respectively, after the first, second and third doses of salbutamol. The risk factors for hypoxia were younger age and a higher modified pulmonary index score, but the risk factors for salbutamol-induced hypoxia were the number of salbutamol doses given in the last six hours and the presence of aeroallergen sensitisation. The maximum decrease in oxygen saturation after salbutamol was %5.

CONCLUSION

Although bronchodilators are the first-line treatment for acute asthma, they caused modest hypoxaemia, especially at repeated doses and, or, in patients with aeroallergen sensitisation.

Pilot Clinical Trial of High-Flow Oxygen Therapy in Children with Asthma in the Emergency Service

OBJECTIVES

To assess the efficacy of high-flow nasal cannula (HFNC) oxygen therapy and safety in children with asthma and moderate respiratory failure in the emergency department (ED).

STUDY DESIGN

This was a prospective randomized pilot trial of children (aged 1-14 years) presenting to a tertiary academic pediatric ED with moderate-to-severe asthma exacerbations between September 2012 and December 2015. Patients with a pulmonary score (PS) ≥6 or oxygen saturation <94% with a face mask despite initial treatment (salbutamol/ipratropium bromide and corticosteroids) were randomized to HFNC or to conventional oxygen therapy. Pharmacologic treatment was at the discretion of attending physicians. The primary outcome was a decrease in PS ≥2 in the first 2 hours. Secondary outcomes included disposition, length of stay, and need for additional therapies.

RESULTS

We randomly allocated 62 children to receive either HFNC (n = 30) or standard oxygen therapy (n = 32). Baseline patient characteristics were similar in the 2 groups. At 2 hours after the start of therapy, PS had decreased by ≥2 points in 16 patients in the HFNC group (53%) compared with 9 controls (28%) (P = .01). Between-group differences in disposition, length of stay, and need for additional therapies were not significant. No side effects were reported.

CONCLUSION

HFNC appears to be superior to conventional oxygen therapy for reducing respiratory distress within the first 2 hours of treatment in children with moderate-to-severe asthma exacerbation refractory to first-line treatment. Further studies are needed to demonstrate its overall efficacy in the management of asthma and respiratory failure in the ED.

TRIAL REGISTRATION

EudraCT: 2012-001771-36.

Randomized Trial of Dexamethasone Versus Prednisone for Children with Acute Asthma Exacerbations

OBJECTIVE

To determine whether 2 doses of dexamethasone is as effective as 5 days of prednisolone/prednisone therapy in improving symptoms and quality of life of children with asthma exacerbations admitted to the emergency department (ED).

STUDY DESIGN

We conducted a randomized, noninferiority trial including patients aged 1-14 years who presented to the ED with acute asthma to compare the efficacy of 2 doses of dexamethasone (0.6 mg/kg/dose, experimental treatment) vs a 5-day course of prednisolone/prednisone (1.5 mg/kg/d, followed by 1 mg/kg/d on days 2-5, conventional treatment). Two follow-up telephone interviews were completed at 7 and 15 days. The primary outcome measures were the percentage of patients with asthma symptoms and quality of life at day 7. Secondary outcomes were unscheduled returns, admissions, adherence, and vomiting.

RESULTS

During the study period, 710 children who met the inclusion criteria were invited to participate and 590 agreed. Primary outcome data were available in 557 patients. At day 7, experimental and conventional groups did not show differences related to persistence of symptoms (56.6%, 95% CI 50.6-62.6 vs 58.3%, 95% CI 52.3-64.2, respectively), quality of life score (80.0 vs 77.7, not significant [ns]), admission rate (23.9% vs 21.7%, ns), unscheduled ED return visits (4.6% vs 3.3%, ns), and vomiting (2.1% vs 4.4%, ns). Adherence was greater in the dexamethasone group (99.3% vs 96.0%, P < .05).

CONCLUSION

Two doses of dexamethasone may be an effective alternative to a 5-day course of prednisone/prednisolone for asthma exacerbations, as measured by persistence of symptoms and quality of life at day 7.

CLINICAL TRIAL REGISTRATION

clinicaltrialsregister.eu: 2013-003145-42.

Initial Asthma Severity Assessment Tools as Predictors of Hospitalization

BACKGROUND

Assessment tools to classify and prioritize patients, such as systems of triage, and indicators of severity, such as clinical respiratory scores, are helpful in guiding the flow of asthmatic patients in the emergency department.

OBJECTIVE

Our aim was to assess the performance of the Pediatric Assessment Triangle (PAT), triage level (TL), Pulmonary Score (PS), and initial O₂ saturation (O₂ sat), in predicting hospitalization in pediatric acute asthma exacerbations.

STUDY DESIGN

Retrospective study evaluating PAT, TL, and PS at presentation, and initial O₂ sat of asthmatic children in the pediatric emergency department (PED). The primary outcome measure was the rate of hospitalization. Secondary outcomes were length of stay (LOS) in the PED and admission to the pediatric intensive care unit (PICU).

RESULTS

PAT, TL, PS, and initial O₂ sat were recorded in 14,953 asthmatic children. Multivariate analysis yielded the following results: Abnormal PAT and more severe TLs (I-II) were independent risk factors for hospitalization (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.4-1.8; OR 3.4, 95% CI 2.6-4.3, respectively) and longer LOS (OR 1.5, 95% CI 1.3-1.7; OR 2.6, 95% CI 2-3.3, respectively). PS > 3 showed a strong association with hospitalization (OR 8.1, 95% CI 7-9.4), PICU admission (OR 9.6, 95% CI 3-30.9) and longer LOS (OR 6.2, 95% CI 5.6-6.9). O₂ sat < 94% was an independent predictor of admission (OR 5.2, 95% CI 4.6-5.9), PICU admission (OR 4.6, 95% CI 4.5-4.6), and longer LOS (OR 4.6, 95% CI 4.1-5.2).

CONCLUSIONS

PAT, TL, PS, and initial O₂ sat are good predictors of hospitalization in pediatric acute asthma exacerbations.

Unplanned reattendances at the paediatric emergency department within 72 hours: a one-year experience in KKH

INTRODUCTION

Unscheduled reattendances at the paediatric emergency department may contribute to overcrowding, which may increase financial burdens. The objectives of this study were to determine the rate of reattendances and characterise factors influencing these reattendances and hospital admission during the return visits.

METHODS

Medical records of all patients who attended the emergency department at KK Women's and Children's Hospital, Singapore, from 1 June 2013 to 31 May 2014 were retrospectively reviewed. We collected data on patient demographics, attendance data and clinical characteristics. Planned reattendances, recalled cases, reattendances for unrelated complaints and patients who left without being seen were excluded. A multivariate analysis was conducted to determine the odds ratio of variables associated with hospital admission for reattendances.

RESULTS

Of 162,566 children, 6,968 (4.3%) returned within 72 hours, and 2,925 (42.0% of reattendance group) were admitted on their return visits. Children more likely to reattend were under three years of age, Chinese, triaged as Priority 2 at the first visit, and were initially diagnosed with respiratory or gastrointestinal conditions. However, children more likely to be admitted on their return visits were over 12 years of age, Malay, had a higher triage acuity or were uptriaged, had the presence of a comorbidity, and were diagnosed with gastrointestinal conditions.

CONCLUSION

We identified certain subgroups in the population who were more likely to be admitted if they reattended. These findings would help in implementing further research and directing strategies to reduce potentially avoidable reattendances and admissions.

Initiation of an Inhaled Corticosteroid During a Pediatric Emergency Visit for Asthma: A Randomized Clinical Trial

STUDY OBJECTIVE

We determine whether prescribing an inhaled corticosteroid during a pediatric emergency department (ED) asthma visit increases ongoing use and improves outcomes.

METHODS

This randomized trial enrolled children aged 1 to 18 years, with persistent asthma not previously prescribed a controller medication, and who were being discharged after ED asthma treatment. Intervention subjects received a 1-month prescription for an inhaled corticosteroid (fluticasone or budesonide by age) in addition to standard asthma therapy and instructions given to all patients. Outcomes included filling of the intervention and subsequent inhaled corticosteroid prescriptions, asthma-related symptoms and quality of life, and follow-up rates with a primary care provider. Outcomes were assessed during telephone interviews 2 and 8 weeks after the ED visit and by review of primary care provider and pharmacy records.

RESULTS

One hundred forty-seven children were enrolled, and baseline measures were similar between groups. In the intervention group, 53.5% of patients filled an initial ED prescription for inhaled corticosteroid. There was no important difference between groups in subsequent filling of a primary care provider prescription (21% intervention versus 17% control; relative rate=1.24; 95% confidence interval 0.63 to 2.41). During the 2 weeks after the ED visit, intervention subjects reported reduced shortness of breath while awake and cough while asleep compared with controls. Groups did not differ by rates of primary care provider follow-up, functional limitations, or asthma-related symptoms and quality of life.

CONCLUSION

There was no difference in the proportion of patients who filled a primary care provider prescription after ED initiation of an inhaled corticosteroid. The intervention was associated with reduced reported symptoms but did not affect other asthma outcomes or primary care provider follow-up.

Emergency department visits for children with acute asthma: discharge instructions, parental plans, and follow-through of care--a prospective study

OBJECTIVE

Communication between emergency department (ED) staff and parents of children with asthma may play a role in asthma exacerbation management. We investigated the extent to which parents of children with asthma implement recommendations provided by the ED staff.

METHOD

We asked questions on asthma triggers, ED care (including education and discharge recommendations), and asthma management strategies used at home shortly after the ED visit and again at 6 months.

RESULTS

A total of 148 children with asthma were recruited. Thirty-two percent of children were not on inhaled corticosteroids prior to their ED visit. Eighty percent of parents identified upper respiratory tract infections (URTIs) as the primary trigger for their child's asthma. No parent received or implemented any specific asthma strategies to reduce the impact of URTIs; 82% of parents did not receive any printed asthma education materials. Most (66%) parents received verbal instructions on how to manage their child's future asthma exacerbations. Of those, one-third of families were told to return to the ED. Parents were rarely advised to bring their child to their family doctor in the event of a future exacerbation. At 6 months, parents continued to use the ED services for asthma exacerbations in their children, despite reporting feeling confident in managing their child's asthma.

CONCLUSION

Improvements are urgently needed in developing strategies to manage pediatric asthma exacerbations related to URTIs, communication with parents at discharge in acute care, and using alternate acute care services for parents who continue to rely on EDs for the initial care of mild asthma exacerbations.

Caregiver's functional status during a young child's asthma exacerbation: A validated instrument

BACKGROUND

Few instruments exist to measure caregivers' functional status during a young child's asthma exacerbation.

OBJECTIVE

We sought to develop and validate a measure of caregivers' functional status during a preschooler's asthma exacerbation.

METHODS

The psychometric properties of the 21-item questionnaire Effects of a Young Child's Asthma Flare-up on the Parents (ECAP) were tested in a randomized placebo-controlled trial of pre-emptive high-dose fluticasone in preschoolers with virus-induced asthma. Caregivers completed the ECAP questionnaire on the last day their child exhibited symptoms of an upper respiratory tract infection or asthma exacerbation (episode). The mean of each item, scored on a scale of 1 (best) to 7 (worst), provided the ECAP score.

RESULTS

Ninety-three preschoolers (2.5 ± 1.0 years old; 62.4% male) experienced 878 episodes. Feasibility (80% questionnaire return rate; 90% completion) and internal consistency (Cronbach α = 0.97) were high. Of 628 episodes with a completed ECAP questionnaire, 621 (98.9%) had data on exacerbations, and 609 (97.0%) had data on health care use. The ECAP score was significantly higher for children experiencing an asthma exacerbation versus those who were not (mean difference, 0.8; 95% CI, 0.6-1.0) and for episodes resulting versus not resulting in an emergency visit (mean difference, 1.2; 95% CI, 1.0-1.4), systemic corticosteroid use (mean difference, 1.4; 95% CI, 1.1-1.7), or hospitalization (mean difference, 1.9; 95% CI, 1.4-2.5). The ECAP score was significantly lower in children treated with fluticasone versus those treated with placebo (mean difference, -0.7; 95% CI, -1.1 to -0.3).

CONCLUSIONS

The 21-item ECAP questionnaire, showing high feasibility, internal consistency, discriminative validity, and responsiveness, has the psychometric properties to serve as a validated outcome to measure the burden of preschoolers' asthma exacerbations on their caregivers' functional status.

Potential predictors of relapse after treatment of asthma exacerbations in children

BACKGROUND

Knowledge of factors that affect relapse will allow close monitoring of patients at risk, resulting in a decreased rate of readmission to the emergency department.

OBJECTIVE

To determine risk factors associated with relapse within 7 days after treatment of asthma exacerbations in children.

METHODS

This was a multicenter, prospective study of children with asthma attacks. Patients between the ages of 6 months and 17 years who met the criteria between June 2009 and September 2012 were considered.

RESULTS

The study included 1177 patients (775 males [65.8%]) with a mean (SD) age of 70.72 (48.24) months. Of them, 199 (16.9%) had a relapse within 1 week after being discharged from the hospital. Factors independently associated with relapse identified by a logistic regression model for the 1,177 study visits were having taken a short-acting inhaled β2-agonist within 6 hours before admission (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.728-3.426; P = .001), presence of retraction on physical examination (OR, 1.76; 95% CI, 1.123-2.774; P = .01), no prescription for high-dose inhaled steroids on release (OR, 2.02; 95% CI, 1.370-3.002; P < .001), and not being given a written instructional plan (OR, 1.55; 95% CI, 1.080-2.226; P = .02).

CONCLUSION

Whereas having taken short-acting β2-agonists within 6 hours before admission and the presence of retractions on physical examination increased the risk of relapse after treatment of the acute attack, being given high-dose inhaled steroids and a written instructional plan when being sent home reduced the risk.

Practice patterns in asthma discharge pharmacotherapy in pediatric emergency departments: a pediatric emergency research Canada study

OBJECTIVES

The objective was to examine utilization of β2 agonists via metered dose inhalers with oral and inhaled corticosteroids (ICS) at discharge in children with acute asthma.

METHODS

This was a retrospective medical record review at six pediatric emergency departments (EDs) of otherwise healthy children 2 to 17 years of age discharged with acute asthma. Data were extracted on history, disease severity, and pharmacotherapy used in the ED and at discharge. The primary outcome was the proportion of children prescribed "comprehensive therapy," i.e., albuterol via metered dose inhaler (MDI) with oral and ICS.

RESULTS

The overall rate of comprehensive therapy was 382 of 654 (58%), which varied from 30% to 84% (p < 0.0001). A total of 570 of 575 children discharged on albuterol received MDIs. Although the rates of prescriptions for oral and ICS were both 80%, only 58% of patients without ICS on arrival were offered ICS at discharge. There was significant variation in the rates of all discharge pharmacotherapies across centers. The independent predictors of comprehensive therapy were daytime presentation (odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.05 to 2.67) and "intensive stabilization" (OR = 2.33, 95% CI = 1.29 to 2.67). Seventeen patients (2.6%) were prescribed antibiotics. Children were more likely to receive antibiotics if they had moderate to severe exacerbations (OR = 2.8) or received a chest radiograph (OR = 8.4).

CONCLUSIONS

The overwhelming majority of children discharged from Canadian pediatric EDs with acute asthma are prescribed inhaled albuterol via MDIs. Although the corticosteroid use at discharge is higher than previously reported, utilization of new prescriptions for ICS may not be optimal. Children presenting during daytime to EDs receiving intensive stabilization are more likely to receive the albuterol/oral steroid/ICS combination.

Urban primary care physicians' perceptions about initiation of controller medications during a pediatric emergency department visit for asthma

OBJECTIVE

This study aimed to identify the beliefs and attitudes of primary care providers (PCPs) regarding emergency department (ED) physicians' initiation of controller medications for children with persistent asthma symptoms during an immediate ED visit.

METHODS

We performed semistructured interviews and a focus group with a purposive sample of PCPs of asthmatic patients to assess attitudes toward the National Asthma and Education Prevention Program recommendations regarding ED-based initiation of controller medications. Interviews and a focus group were digitally recorded, transcribed, and entered into qualitative software for coding and analysis. A multidisciplinary team used content analysis to identify important themes.

RESULTS

A total of 22 pediatricians and 1 nurse practitioner participated, and content saturation was achieved. Of all participants, 57% were from hospital-based practices and 43% were from non-hospital-based practices. All agreed with the new guideline recommendation that emergency medicine physicians should consider initiating controller medications during a short-term visit for asthma. Four major themes were identified: (1) the importance of communication and collaboration between primary care and ED practitioners, (2) patients must meet criteria for inhaled corticosteroids and provide a reliable history, (3) the ED visit offers a lost opportunity for education and may represent a teachable moment, and (4) the ED visit provides a chance to capture patients with frequent exacerbations who are noncompliant with follow-up visits.

CONCLUSIONS

Primary care providers who participated in this study believed that the ED visit offers a valuable opportunity for the initiation of controller medications when ED providers use guideline-based criteria and communicate the intervention to the PCP.

A 5- versus 3-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalised: a randomised controlled trial

OBJECTIVE

To determine whether a 5-day course of oral prednisolone is superior to a 3-day course in reducing the 2-week morbidity of children with asthma exacerbations who are not hospitalised.

DESIGN, SETTING AND PARTICIPANTS

Double-blind randomised controlled trial of asthma outcomes following a 5-day course of oral prednisolone (1 mg/kg) compared with a 3-day course of prednisolone plus placebo for 2 days. Participants were children aged 2-15 years who presented to the emergency departments of three Queensland hospitals between March 2004 and February 2007 with an acute exacerbation of asthma, but were not hospitalised. Sample size was defined a priori for a study power of 90%.

MAIN OUTCOME MEASURES

Difference in proportion of children who were symptom-free at Day 7, as measured by intention-to-treat (ITT) and per-protocol analysis; quality of life (QOL) on Days 7 and 14.

RESULTS

201 children were enrolled, and there was an 82% completion rate. There was no difference between groups in the proportion of children who were symptom-free (observed difference, 0.04 [95% CI, - 0.09 to 0.18] by ITT analysis; 0.04 [95% CI, - 0.17 to 0.09] by per-protocol analysis). There was also no difference between groups in QOL (P = 0.42). The difference between groups for the primary outcome was within the equivalence range calculated post priori.

CONCLUSION

A 5-day course of oral prednisolone confers no advantage over a 3-day course for children with asthma exacerbations who are not hospitalised.

TRIAL REGISTRATION

Australian Clinical Trials Registry ACTRN012605000305628.

Risk factors for repeat adverse asthma events in children after visiting an emergency department

Objective

The aim of this study was to identify risk factors for long-term adverse outcomes in children with asthma after visiting the emergency department (ED).

Methods

A prospective observational study was conducted at the ED of a pediatric tertiary hospital in Ontario, Canada. Patient outcomes (ie, acute asthma episodes and ED visits) were measured at baseline and at 1- and 6-months post-ED discharge. Time trends in outcomes were assessed using the generalized estimating equations method. Multiple conditional logistic regressions were used to model outcomes at 6 months and examine the impact of drug insurance coverage while adjusting for confounders.

Results

Of the 269 children recruited, 81.8% completed both follow-ups. ED use significantly reduced from 39.4% at baseline to 26.8% at 6 months (P < .001), whereas the level of acute asthma episodes remained unchanged. Children with drug insurance coverage were less likely to have acute asthma episodes (adjusted odds ratio [AOR] = 0.36; 95% CI, 0.15–0.85; P < .02) or repeat ED visits (AOR = 0.45; 95% CI, 0.20–0.99; P < .05) at 6 months. Other risk factors for adverse outcomes included previous adverse asthma events and certain asthma triggers (eg, cold/sinus infection). Washing bed linens in hot water weekly was protective against subsequent acute asthma episodes.

Conclusions

Our study demonstrated significant improvements in long-term outcomes in children seeking acute care for asthma in the ED. Future efforts remain in targeting the sustainability of improved outcomes beyond 6 months. Risk factors identified can help target vulnerable populations for proper interventions, which may include efforts to maximize insurance coverage for asthma medications and strategies to improve asthma self-management through patient and provider education.

Effectiveness of emergency department asthma management strategies on return visits in children: a population-based study

BACKGROUND

Emergency departments play an important role in the care of children with asthma. Emergency department return-visit rates provide a measure of the quality of acute asthma care.

OBJECTIVE

Our goal was to describe the characteristics of children treated in emergency departments for asthma, the resources and asthma management strategies used by emergency departments, and their effect on return visits within 72 hours.

DESIGN, SETTING, AND PATIENTS

We used a population-based cohort study that incorporated both comprehensive administrative heath and survey data from all 152 emergency departments in Ontario, Canada. We studied all 2- to 17-year-old children who had a visit to an emergency department for asthma from April 2003 to March 2005.

RESULTS

A total of 32,996 children (>9% of children with asthma in Ontario) had at least 1 visit to an emergency department for the care of asthma, and most of these visits (68.5%) were triaged as high acuity. The vast majority (148 of 152 [97%]) of emergency departments reported using at least 1 asthma management strategy, and 74% used 3 or more. The overall return-visit rate was 5.6%. Logistic regression models that accounted for the clustering of patients in emergency departments and controlled for patient and emergency department characteristics indicated that preprinted order sheets and access to a pediatrician for consultation were strategies significantly associated with a reduction in return visits. The 11 (17%) emergency departments that used both of these strategies had return visit rates of 4.4% compared with 6.9% in the 95 (63%) that used neither strategy.

CONCLUSIONS

Emergency departments use a range of strategies to manage asthma in children. Preprinted order sheets and access to pediatricians are associated with important reductions in return-visit rates, and more emergency departments should consider using these strategies.

Screening for poor short-term outcome in acute pediatric asthma

BACKGROUND

Despite good initial treatment response, many children with acute asthma exacerbations have poor short-term outcomes.

OBJECTIVE

To develop and validate a risk score to screen for poor short-term outcome at the time of emergency department (ED) treatment.

METHODS

Prospective cohort study of children treated for acute asthma at 2 pediatric EDs. Poor 14-day outcome was defined as any of the following: asthma symptoms still above baseline at 14 days, child missed 5 or more days of school or day care, caretaker missed 5 or more days of school or work, or unscheduled care or admission after the ED visit for worsening symptoms.

RESULTS

A total of 1,221 children were enrolled: 852 at the derivation site and 369 at the validation site. Five variables independently associated with poor outcome by logistic regression were used to create a simple linear score: wheezing 2 or more days before the visit, 3 or more acute outpatient asthma visits in the previous 12 months, home use of albuterol, history of severe persistent asthma, and fever at the ED visit. Area under the receiver operating characteristic curve values were 0.66/0.67 for the derivation/validation samples. Two or more features categorized high risk. The test characteristics for the derivation/validation samples are as follows: sensitivity, 0.67/0.62; specificity, 0.61/0.68; likelihood ratio, 1.7/1.9; pretest probability, 33%/47%; and posttest probability, 50%/62%.

CONCLUSIONS

Information available at the ED visit was used to develop a simple risk score that identifies patients at high risk for poor outcome. The score would be useful in evaluating interventions to improve outcomes by allowing interventions to be targeted to a subgroup most likely to benefit.

Improving pediatric asthma care through surveillance: the Illinois Emergency Department Asthma Collaborative

OBJECTIVES

To better understand and improve the care of asthma patients who require emergency department (ED) care, the Illinois Emergency Department Asthma Collaborative (IEDAC) was created to develop, test, and disseminate an ED-based surveillance system. This report describes the development and testing of the pediatric IEDAC surveillance instruments and demonstrates how these instruments can be used to describe the health status, healthcare delivery, and outcome of children using ED services.

METHODS

A convenience sample of 128 children presenting to 5 EDs in Illinois for asthma care was the study base. Data were collected on monthly samples of children aged 2 through 17 years who presented to these EDs from May to November 2003. Three instruments were used to collect data regarding the children's pre-ED, ED, and post-ED experience.

RESULTS

At the ED visit, 73.4% of children met national guideline criteria for persistent-level asthma symptoms. Among this group, 53.2% were using inhaled corticosteroid (ICS) medications. At 1 month follow-up, 66.6% of the children met the criteria for persistent-level asthma symptoms, which was statistically unchanged from the ED visit. Among the latter group, 64.2% were using ICS medications, again statistically unchanged compared with the ED visit. At follow-up, 24.5% of children were reported to have returned to an ED or were subsequently hospitalized. The majority of children were noted at follow-up to have limitation of at least some activity.

CONCLUSIONS

Children who presented to IEDAC EDs were found to have a high level of asthma burden that continued at follow-up despite treatment. Moreover, a substantial proportion of children had returned to an ED or were subsequently hospitalized. Encouraging trends in medication use were observed, although suboptimal medication use was also observed.

Short-term clinical outcomes of acute treatment of childhood asthma

PURPOSE OF REVIEW

Acute exacerbations of asthma are the leading cause of emergency department visits in the pediatric patient. The present review is focused on the identification of those factors that may contribute to improving the short-term outcome of children after discharge from an emergency department visit for acute asthma.

RECENT FINDINGS

Several recent studies have documented that children treated at the emergency department because of an asthma-related event present a high morbidity at 7 and 15 days after discharge, mainly associated with symptom persistence, need for rescue bronchodilator medication, and absenteeism from school or day nursery. A better control of the disease, particularly adequate outpatient follow-up and maintenance treatment with inhaled steroids, could improve short-term clinical outcomes.

SUMMARY

All efforts of emergency room management of children with asthma, identification of severity of the current exacerbation episode, and intensive treatment of the acute asthma attack have usually been directed at reducing the rates of hospitalization and the return for medical care. However, according to reported data on short-term morbidity, it is necessary to define therapeutic and follow-up strategies after treatment for acute asthma and emergency department discharge. Besides standard treatment for an acute asthma exacerbation in a pediatric emergency department, action plans should include a review of the maintenance treatment of asthma to improve underlying disease control and a strong recommendation for close follow-up by the primary care pediatrician.