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Prospective Observational Study of Clinical Outcomes After Intravenous Magnesium for Moderate and Severe Acute Asthma Exacerbations in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1238-1246. [PMID: 34915226 PMCID: PMC9086103 DOI: 10.1016/j.jaip.2021.11.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND There is limited knowledge regarding whether intravenous magnesium (IV-Mg) improves outcomes in children with acute asthma exacerbations. OBJECTIVE To examine whether IV-Mg improves outcomes in children with moderate and severe exacerbations. METHODS We performed a secondary analysis using data from a prospective observational cohort of children aged 5 to 17 years with moderate and severe exacerbations. Standardized treatment included systemic corticosteroid and inhaled albuterol, with consideration of IV-Mg (75 mg/kg) for patients with insufficient response after 20 minutes. Propensity score (PS) models were used to examine associations of IV-Mg treatment with change in the validated Acute Asthma Intensity Research Score, hospitalization rate, and time to spacing of inhaled albuterol of 4 hours or more among hospitalized participants. RESULTS Among 301 children, median (interquartile range) age was 8.1 (6.4-10.2) years, 170 were Black (57%), 201 were male (67%), and 84 received IV-Mg (28%). In a PS covariate-adjusted multivariable linear regression model, IV-Mg treatment was associated with a 2-hour increase in the Acute Asthma Intensity Research Score (β-coefficient = 0.98; 95% confidence interval [CI], 0.20-1.77), indicating increased exacerbation severity. Three additional PS-based models yielded similar results. Participants receiving IV-Mg had 5.8-fold (95% CI, 2.8-11.9) and 6.8-fold (95% CI, 3.6-12.9) greater odds of hospitalization in PS-based multivariable regression models. Among hospitalized participants, there was no difference in time to albuterol of every 4 hours or more in a PS covariate-adjusted Cox proportional hazards model (hazard ratio = 1.2; 95% CI, 0.8-1.8). CONCLUSIONS Among children with moderate and severe exacerbations, IV-Mg is associated with increased exacerbation severity, increased risk for hospitalization, and no acceleration in exacerbation resolution among hospitalized participants.
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2
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Burger C, Vendiola DF, Arnold DH. Nebulized albuterol delivery is associated with decreased skeletal muscle strength in comparison with metered-dose inhaler delivery among children with acute asthma exacerbations. J Am Coll Emerg Physicians Open 2021; 2:e12422. [PMID: 33855311 PMCID: PMC8032924 DOI: 10.1002/emp2.12422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/25/2021] [Accepted: 03/10/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Albuterol is a β2-agonist and causes an intracellular shift of potassium from the interstitium. Whole-body hypokalemia is known to cause skeletal muscle weakness, but whether this occurs as a result of hypokalemia from the intracellular shift during albuterol treatment is unknown. We sought to determine if albuterol total dose or route of administration (nebulization and/or metered-dose inhaler) is associated with skeletal muscle weakness. METHODS This was a prospective observational study using convenience sampling. Skeletal muscle strength was measured before and after 1 hour of albuterol treatment using a hand-grip dynamometer in participants aged 5-17 years with acute asthma exacerbation in the emergency department. We examined associations of albuterol dose and route of administration with changes in grip strength. RESULTS Among 50 participants, 10 received continuous albuterol by nebulizer and 40 received albuterol by metered-dose inhaler. The median (interquartile range) in change of grip was -7.8% (interquartile range, -23.3, +5.1) for those treated with a nebulizer and +2.4% (interquartile range, -5%, +12.7%) for those treated with a metered-dose inhaler (P = 0.036 for the difference). In a multiple linear regression model adjusted for the pretreatment Acute Asthma Intensity Research Score and age, participants treated with a nebulizer had a 12.9% decrease in skeletal muscle strength compared with those treated with a metered-dose inhaler. CONCLUSION Higher doses of albuterol administered via nebulization result in decreased skeletal muscle strength in patients with acute asthma; whereas, albuterol administration via metered-dose inhalers showed no effect on skeletal muscle strength.
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Affiliation(s)
- Catherine Burger
- Department of PediatricsDivision of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Danica F. Vendiola
- Vanderbilt Undergraduate Clinical Research Internship ProgramNashvilleTennesseeUSA
| | - Donald H. Arnold
- Department of PediatricsDivision of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Center for Asthma ResearchVanderbilt University School of MedicineNashvilleTennesseeUSA
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3
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Abecassis L, Gaffin JM, Forbes PW, Schenkel SR, McBride S, DeGrazia M. Validation of the Hospital Asthma Severity Score (HASS) in children ages 2-18 years old. J Asthma 2020; 59:315-324. [PMID: 33198536 DOI: 10.1080/02770903.2020.1852414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The Hospital Asthma Severity Score (HASS) was developed to communicate inpatient asthma severity between providers. The purpose of this prospective study was to validate the HASS against the Pediatric Respiratory Assessment Measure (PRAM) and spirometry for assessment of inpatient asthma exacerbation severity in patients 2-18 years old, at a single point-in-time. METHODS This study was registered with clinicaltrials.gov (NCT02782065). Children admitted to a tertiary care, free-standing children's hospital were assessed for asthma severity using the HASS, PRAM, and pulmonary function by spirometry. Inter-rater agreement of HASS and PRAM scores was assessed between two blinded clinician raters. Spirometry results were obtained by a certified pulmonary laboratory technician and correlated with HASS and PRAM scores. RESULTS The sample included 58 subjects. Allowing for a one-point difference in continuous HASS and PRAM scores, inter-rater agreement was 79% for the HASS and 60% for the PRAM. When the scores were categorized as mild, moderate, and severe, inter-rater agreement was 62% for the HASS and 93% for the PRAM (p < .0001). Additionally, intra-rater agreement between HASS and PRAM severity categories was 71% for Rater 1 and 64% for Rater 2. A weak correlation was noted between both the HASS and FEV1 (r = -0.31; p = 0.11), and PRAM and FEV1 (r = -0.30; p = 0.11) for the 29 subjects with acceptable spirometry results. CONCLUSIONS The HASS and PRAM have acceptable inter-rater and intra-rater agreement. These results support validation of the HASS for managing hospitalized patients during asthma exacerbations.
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Affiliation(s)
- Leah Abecassis
- Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, MA, USA
| | - Jonathan M Gaffin
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Peter W Forbes
- Clinical Research Center, Boston Children's Hospital, Boston, MA, USA
| | - Sara R Schenkel
- Division of Pediatric Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah McBride
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Michele DeGrazia
- Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
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4
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Chacko J, King C, Harkness D, Messahel S, Grice J, Roe J, Mullen N, Sinha IP, Hawcutt DB. Pediatric acute asthma scoring systems: a systematic review and survey of UK practice. J Am Coll Emerg Physicians Open 2020; 1:1000-1008. [PMID: 33145551 PMCID: PMC7593416 DOI: 10.1002/emp2.12083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/30/2020] [Accepted: 04/08/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acute exacerbations of asthma are common in children. Multiple asthma severity scores exist, but current emergency department (ED) use of severity scores is not known. METHODS A systematic review was undertaken to identify the parameters collected in pediatric asthma severity scores. A survey of Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI) sites was undertaken to ascertain routinely collected asthma data and information about severity scores. Included studies examined severity of asthma exacerbation in children 5-18 years of age with extractable severity parameters. RESULTS Sixteen articles were eligible, containing 17 asthma severity scores. The severity scores assessed combinations of 15 different parameters (median, 6; range, 2-8). The most common parameters considered were expiratory wheeze (15/17), inspiratory wheeze (13/17), respiratory rate (10/17), and general accessory muscle use (9/17). Fifty-nine PERUKI centers responded to the questionnaire. Twenty centers (33.1%) currently assess severity, but few use a published score. The most commonly recorded routine data required for severity scores were oxygen saturations (59/59, 100%), heart rate, and respiratory rate (58/59, 98.3% for both). Among well-validated scores like the Pulmonary Index Score (PIS), Pediatric Asthma Severity Score (PASS), Childhood Asthma Score (CAS), and the Pediatric Respiratory Assessment Measure (PRAM), only 6/59 (10.2%), 3/59 (5.1%), 1/59 (1.7%), and 0 (0%) of units respectively routinely collect the data required to calculate them. CONCLUSION Standardized published pediatric asthma severity scores are infrequently used. Improved routine data collection focusing on the key parameters common to multiple scores could improve this, facilitating research and audit of pediatric acute asthma.
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Affiliation(s)
- Jerry Chacko
- School of MedicineUniversity of LiverpoolLiverpoolUK
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpoolUK
| | - Charlotte King
- Royal Liverpool and Broadgreen University Hospital TrustLiverpoolUK
| | - David Harkness
- National Institute for Health Research Alder Hey Clinical Research FacilityAlder Hey Children's HospitalLiverpoolUK
| | - Shrouk Messahel
- Emergency DepartmentAlder Hey Children's HospitalLiverpoolUK
| | - Julie Grice
- Emergency DepartmentAlder Hey Children's HospitalLiverpoolUK
| | - John Roe
- Darwin Emergency DepartmentDarwinNorthern TerritoryAustralia
| | - Niall Mullen
- Paediatric Emergency MedicineSunderland Royal HospitalSunderlandUK
| | - Ian P. Sinha
- Department of Respiratory MedicineAlder Hey Children's HospitalLiverpoolUK
| | - Daniel B. Hawcutt
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpoolUK
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DeSanti RL, Agasthya N, Hunter K, Hussain MJ. The effectiveness of magnesium sulfate for status asthmaticus outside the intensive care setting. Pediatr Pulmonol 2018; 53:866-871. [PMID: 29660840 DOI: 10.1002/ppul.24013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 03/21/2018] [Indexed: 11/07/2022]
Abstract
AIM Magnesium is an adjunctive therapy used in patients with status asthmaticus who do not respond to conventional therapy. The optimal time from initiation of therapy, to determination of response and administration of magnesium has not yet been resolved. Our objective was to determine if magnesium administered in the non-intensive care setting can decrease duration of continuous albuterol and hospital length of stay. METHODS We performed a retrospective cohort analysis of children ages 2-18 years admitted to the pediatric unit on continuous albuterol between January 2014 and December 2015 in a tertiary care children's hospital. Cohorts were matched on respiratory assessment score (RAS) obtained at a similar duration of albuterol therapy and evaluated for the total duration of continuous albuterol, length of stay (LOS), and adverse events. RESULTS Thirty-three patients who received magnesium were matched to 33 patients with the same RAS at a similar duration of continuous albuterol therapy who did not receive magnesium. Those who received magnesium had longer duration on continuous albuterol (34 vs 18 h; P = 0.001; 95% confidence interval [CI] 4-20; effect size 0.41) and longer LOS (72 vs 49 h; P = 0.037; 95% confidence interval [CI] 1-33; effect size 0.26) than those who did not receive magnesium. CONCLUSION Children requiring continuous albuterol for status asthmaticus can be administered magnesium sulfate outside the PICU with a low incidence of adverse events; however, among a RAS matched cohort, those who received magnesium did not experience shorter time on continuous albuterol, or hospital length of stay.
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Affiliation(s)
- Ryan L DeSanti
- Department of Pediatric Critical Care, University of Wisconsin, Madison, Wisconsin
| | - Nisha Agasthya
- Department of Pediatric Critical Care, Nemours/Alfred I DuPont Hospital for Children, Wilmington, Delaware
| | - Krystal Hunter
- Cooper Research Institute, Cooper University Hospital, Camden, New Jersey.,Cooper Medical School of Rowan University, Camden, New Jersey
| | - Mohammed J Hussain
- Cooper Medical School of Rowan University, Camden, New Jersey.,Department of Pediatrics, Cooper University Hospital, Camden, New Jersey.,Weisman Children's Rehabilitation Hospital, Marlton, New Jersey
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6
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Patel SJ, Arnold DH, Topoz I, Sills MR. Literature Review: Prediction Modeling of Emergency Department Disposition Decisions for Children with Acute Asthma Exacerbations. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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7
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Magpuri AT, Dixon JK, McCorkle R, Crowley AA. Adapting an Evidence-Based Pediatric Acute Asthma Exacerbation Severity Assessment Tool for Pediatric Primary Care. J Pediatr Health Care 2018; 32:10-20. [PMID: 28927681 DOI: 10.1016/j.pedhc.2017.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/08/2017] [Accepted: 06/12/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The purposes of this project were (a) to examine criteria derived from evidence-based pediatric acute asthma exacerbation assessment tools, asthma scores, and the acute asthma prediction rule validated and used in the emergency department and (b) to adapt these criteria for pediatric primary care. METHOD The three stages of the project included (a) identification of criteria in a literature review, (b) validation of the criteria by an expert panel, and (c) adaptation of the criteria in the design of an assessment tool. RESULTS The criteria were validated and adapted in the design of The Pediatric Acute Asthma Exacerbation Severity Assessment and Disposition Decision-Making Tool for Pediatric Primary Care. DISCUSSION The adaptation of criteria derived from the evidence and validated by an expert panel will inform and guide clinicians in assessing severity and support decision making in determining disposition of pediatric patients presenting with an acute asthma exacerbation in primary care.
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Maekawa T, Ohya Y, Mikami M, Uematsu S, Ishiguro A. Clinical Utility of the Modified Pulmonary Index Score as an Objective Assessment Tool for Acute Asthma Exacerbation in Children. JMA J 2018; 1:57-66. [PMID: 33748523 PMCID: PMC7969834 DOI: 10.31662/jmaj.2018-0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/27/2018] [Indexed: 12/22/2022] Open
Abstract
Introduction: The Modified Pulmonary Index Score (MPIS) was developed as an objective assessment tool for acute asthma exacerbation in children. Although it is considered reliable, there are no known studies of its clinical utility. The objective of this study was to evaluate the validity of the MPIS for children with acute asthma in a clinical setting. Methods: In this retrospective study conducted between July 2009 and June 2011 using electronic medical records at the emergency department of a single pediatric medical center in Tokyo, Japan, the MPIS was recorded for patients with acute asthma at initial assessment and after treatment with an inhaled beta-agonist. We evaluated the responsiveness and predictive validity of the MPIS using disposition as an outcome. Results: A total of 2242 patients were assessed using the MPIS (median age, 3 years; 71.2% patients were 5 years or younger). The mean (SD) MPIS at initial assessment was 7.1 (3.6) and was significantly higher for the admission group than for the non-admission group (9.9 [2.9] vs. 5.9 [3.1]; P < 0.001). The receiver operator characteristic curve of the initial MPIS for hospital admission demonstrated moderate predictive ability (area under the curve, 0.83). An MPIS reduction of 3 or more indicated a clinically significant change when the MPIS at initial assessment was between 6 and 10 (risk ratio for admission [95% CI], 0.41 [0.28–0.60]; P < 0.001). Conclusion: The MPIS demonstrated good concurrent validity, predictive validity, and responsiveness in a wide range of clinical settings.
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Affiliation(s)
- Takanobu Maekawa
- Division of Pediatrics, Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yukihiro Ohya
- Division of Allergy, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Masashi Mikami
- Division of Biostatistics, Center for Clinical Research, National Center for Child Health and Development, Tokyo, Japan
| | - Satoko Uematsu
- Division of Emergency Service and Transport Medicine, Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Akira Ishiguro
- Department of Postgraduate Education and Training, National Center for Child Health and Development, Tokyo, Japan
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9
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Arnold DH, Johnson DP, Yang CL, Hartert TV. Forced expiratory values in 1 second corresponding to Pediatric Respiratory Assessment Measure and Acute Asthma Intensity Research Score values during pediatric acute asthma exacerbations. Ann Allergy Asthma Immunol 2017; 119:561-562. [PMID: 29107465 DOI: 10.1016/j.anai.2017.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/04/2017] [Accepted: 09/07/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Donald H Arnold
- Division of Emergency Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; The Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - David P Johnson
- Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Connie L Yang
- Division of Respiratory Medicine, Department of Pediatrics, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Tina V Hartert
- The Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee; Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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Justicia-Grande AJ, Pardo Seco J, Rivero Calle I, Martinón-Torres F. Clinical respiratory scales: which one should we use? Expert Rev Respir Med 2017; 11:925-943. [PMID: 28974118 DOI: 10.1080/17476348.2017.1387052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION There are countless clinical respiratory scales for acute dyspnoea. Most healthcare professionals choose one based on previous personal experience or following local practice, unaware of the implications of their choice. The lack of critical comparisons between those different tools has been a widespread problem that only recently has begun to be addressed via score validation studies. Here we try to assess and compare the quality criteria of measurement properties of acute dyspnoea scores. Areas covered: A literature review was conducted by searching the PubMed database. Forty-five documents were deemed eligible as they reported the use or building of clinical scales, using at least two parameters, and applied these to an acute episode of respiratory dyspnoea. Our primary focus was the description of the validity, reliability and utility of 41 suitable scoring instruments. Differences in sample selection, study design, rater profiles and potential methodological shortcomings were also addressed. Expert commentary: All acute dyspnoea scores lack complete validation. In particular, the areas of measurement error and interpretability have not been addressed correctly by any of the tools reviewed. Frequent modification of pre-existing scores (in items composition and/or name), differences in study design and discrepancies in reviewed sources also hinder the search for an adequate tool.
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Affiliation(s)
- Antonio José Justicia-Grande
- a Translational Pediatrics and Infectious Diseases, Department of Pediatrics , Hospital Clínico Universitario de Santiago de Compostela , A Coruña , Spain.,b Healthcare Research Institute , Instituto de Investigación Sanitaria de Santiago, GENVIP group , Santiago de Compostela, A Coruña , Spain
| | - Jacobo Pardo Seco
- b Healthcare Research Institute , Instituto de Investigación Sanitaria de Santiago, GENVIP group , Santiago de Compostela, A Coruña , Spain
| | - Irene Rivero Calle
- a Translational Pediatrics and Infectious Diseases, Department of Pediatrics , Hospital Clínico Universitario de Santiago de Compostela , A Coruña , Spain.,b Healthcare Research Institute , Instituto de Investigación Sanitaria de Santiago, GENVIP group , Santiago de Compostela, A Coruña , Spain
| | - Federico Martinón-Torres
- a Translational Pediatrics and Infectious Diseases, Department of Pediatrics , Hospital Clínico Universitario de Santiago de Compostela , A Coruña , Spain.,b Healthcare Research Institute , Instituto de Investigación Sanitaria de Santiago, GENVIP group , Santiago de Compostela, A Coruña , Spain
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Johnson MD, Nkoy FL, Sheng X, Greene T, Stone BL, Garvin J. Direct concurrent comparison of multiple pediatric acute asthma scoring instruments. J Asthma 2017; 54:741-753. [PMID: 27831833 PMCID: PMC5425314 DOI: 10.1080/02770903.2016.1258081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Appropriate delivery of Emergency Department (ED) treatment to children with acute asthma requires clinician assessment of acute asthma severity. Various clinical scoring instruments exist to standardize assessment of acute asthma severity in the ED, but their selection remains arbitrary due to few published direct comparisons of their properties. Our objective was to test the feasibility of directly comparing properties of multiple scoring instruments in a pediatric ED. METHODS Using a novel approach supported by a composite data collection form, clinicians categorized elements of five scoring instruments before and after initial treatment for 48 patients 2-18 years of age with acute asthma seen at the ED of a tertiary care pediatric hospital ED from August to December 2014. Scoring instruments were compared for inter-rater reliability between clinician types and their ability to predict hospitalization. RESULTS Inter-rater reliability between clinician types was not different between instruments at any point and was lower (weighted kappa range 0.21-0.55) than values reported elsewhere. Predictive ability of most instruments for hospitalization was higher after treatment than before treatment (p < 0.05) and may vary between instruments after treatment (p = 0.054). CONCLUSIONS We demonstrate the feasibility of comparing multiple clinical scoring instruments simultaneously in ED clinical practice. Scoring instruments had higher predictive ability for hospitalization after treatment than before treatment and may differ in their predictive ability after initial treatment. Definitive conclusions about the best instrument or meaningful comparison between instruments will require a study with a larger sample size.
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Affiliation(s)
- Michael D. Johnson
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Flory L. Nkoy
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
- Department of Biomedical Informatics, University of Utah School of
Medicine, Suite 140, 421 Wakara Way, Salt Lake City, UT 84108, USA
| | - Xiaoming Sheng
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Tom Greene
- Department of Population Health Sciences, University of Utah School
of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Bryan L. Stone
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Jennifer Garvin
- Department of Biomedical Informatics, University of Utah School of
Medicine, Suite 140, 421 Wakara Way, Salt Lake City, UT 84108, USA
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Walsh CG, Sills MR, Arnold DH. Time-dependent severity change during treatment of pediatric patients hospitalized for acute asthma exacerbations. Ann Allergy Asthma Immunol 2016; 118:226-227. [PMID: 27865715 DOI: 10.1016/j.anai.2016.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/24/2016] [Accepted: 10/26/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Colin G Walsh
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Marion R Sills
- Departments of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado; Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Donald H Arnold
- Division of Emergency Medicine, Department of Pediatrics, Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee.
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Arnold DH, Sills MR, Walsh CG. The asthma prediction rule to decrease hospitalizations for children with asthma. Curr Opin Allergy Clin Immunol 2016; 16:201-9. [PMID: 26918532 PMCID: PMC5380119 DOI: 10.1097/aci.0000000000000259] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The aim of the present review was to discuss the challenges around clinical decision-making for hospitalization of children with acute asthma exacerbations and the development, internal validation, and future potential of the asthma prediction rule (APR) to provide meaningful clinical decision-support that might decrease unnecessary hospitalizations. RECENT FINDINGS The APR was developed and internally validated using predictor variables available before treatment in the emergency department, and performed well to predict 'need-for-hospitalization.' Oxygen saturation on room air and expiratory phase prolongation were most strongly associated with need-for-hospitalization. SUMMARY Research on prediction rules in pediatric asthma is rare. We developed and internally validated the APR using clinically intuitive predictor variables that are available at the bedside. Before incorporation into electronic decision-support the APR must undergo external validation and an impact analysis to determine if use of this tool will change clinician behavior and improve patient outcomes.
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Affiliation(s)
- Donald H Arnold
- aDivision of Emergency Medicine, Department of Pediatrics and Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee bSection of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado cDepartment of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Pardue Jones B, Fleming GM, Otillio JK, Asokan I, Arnold DH. Pediatric acute asthma exacerbations: Evaluation and management from emergency department to intensive care unit. J Asthma 2016; 53:607-17. [PMID: 27116362 DOI: 10.3109/02770903.2015.1067323] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The goal of this report is to review available modalities for assessing and managing acute asthma exacerbations in pediatric patients, including some that are not included in current expert panel guidelines. While it is not our purpose to provide a comprehensive review of the National Asthma Education and Prevention Program (NAEPP) guidelines, we review NAEPP-recommended treatments to provide the full range of treatments available for managing exacerbations with an emphasis on the continuum of care between the ER and ICU. DATA SOURCES We searched PubMed using the following search terms in different combinations: asthma, children, pediatric, exacerbation, epidemiology, pathophysiology, guidelines, treatment, management, oxygen, albuterol, β2-agonist, anticholinergic, theophylline, corticosteroid, magnesium, heliox, BiPAP, ventilation, mechanical ventilation, non-invasive mechanical ventilation and respiratory failure. We attempted to weigh the evidence using the hierarchy in which meta-analyses of randomized controlled trials (RCTs) provide the strongest evidence, followed by individual RCTs, followed by observational studies. We also reviewed the NAEPP and Global Initiative for Asthma expert panel guidelines. RESULTS AND CONCLUSIONS Asthma is the most common chronic disease of childhood, and acute exacerbations are a significant burden to patients and to public health. Optimal assessment and management of exacerbations, including appropriate escalation of interventions, are essential to minimize morbidity and prevent mortality. While inhaled albuterol and systemic corticosteroids are the mainstay of exacerbation management, escalation may include interventions discussed in this review.
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Affiliation(s)
| | | | | | | | - Donald H Arnold
- a Department of Pediatrics , Division of Emergency Medicine.,d Center for Asthma Research, Vanderbilt University School of Medicine , Nashville , TN , USA
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Arnold DH, Wang L, Hartert TV. Pulse Oximeter Plethysmograph Estimate of Pulsus Paradoxus as a Measure of Acute Asthma Exacerbation Severity and Response to Treatment. Acad Emerg Med 2016; 23:315-22. [PMID: 26727986 DOI: 10.1111/acem.12886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 10/09/2015] [Accepted: 10/10/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Pulsus paradoxus is one of the few objective bedside measures of acute asthma exacerbation severity but is difficult to measure in tachypneic and tachycardic patients and in noisy clinical environments. Our primary objective was to examine whether pulse oximeter plethysmograph estimate of pulsus paradoxus (PEP) is associated with physiologic and symptom measures of acute exacerbation severity (airway resistance by impulse oscillometry [%IOS] and the Acute Asthma Intensity Research Score [AAIRS]). Secondary objectives were to validate the previous association of PEP with percent predicted forced expiratory volume in 1 second (%FEV1 ) and to examine associations of change of PEP with change of these outcomes after 2 hours of treatment. METHODS This was a secondary analysis of data from a prospective observational study of patients aged 5-17 years with acute asthma exacerbations. The predictor variable, PEP, was measured using a dedicated pulse oximeter and waveform analysis program. Outcome measures included the AAIRS, %IOS, and %FEV1 at baseline and after 2 hours of treatment. We examined associations of PEP with %IOS and the AAIRS at baseline using multiple linear regression models adjusted for age, sex, and race. As secondary analyses we similarly examined the association of PEP with %FEV1 at baseline and change of PEP with change of %IOS, the AAIRS, and %FEV1 after 2 hours of treatment using multiple linear regression models adjusted for the baseline value of the outcome measure and the AAIRS. RESULTS Among 684 participants (61% males; 61% African American) there were associations of baseline PEP with %IOS, the AAIRS, and %FEV1 (p < 0.001). Change of PEP after 2 hours of treatment was associated with change of %FEV1 (p < 0.001) and change of the AAIRS (p = 0.01) but not with change of %IOS (p = 0.60). CONCLUSIONS PEP demonstrates criterion validity in predicting baseline %IOS, the AAIRS, and %FEV1 , and responsiveness to change of the AAIRS and %FEV1 . Data contained in the oximeter plethysmograph waveform might be utilized as a continuous, objective measure of acute asthma exacerbation severity and real-time response to treatment.
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Affiliation(s)
- Donald H. Arnold
- Department of Pediatrics; Division of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
- Center for Asthma Research; Vanderbilt University School of Medicine; Nashville TN
| | - Li Wang
- Department of Biostatistics; Vanderbilt University School of Medicine; Nashville TN
| | - Tina V. Hartert
- Department of Medicine; Division of Allergy, Pulmonary & Critical Care Medicine; Vanderbilt University School of Medicine; Nashville TN
- Center for Asthma Research; Vanderbilt University School of Medicine; Nashville TN
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Berg KT, O'Connor MG, Lescallette RD, Arnold DH, Stack LB. AAIRS Score Overview: The Acute Asthma Intensity Research Score. Acad Emerg Med 2015; 22:E25-6. [PMID: 26352797 DOI: 10.1111/acem.12760] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Kathleen T. Berg
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - Michael G. O'Connor
- Division of Pulmonary Medicine; Department of Pediatrics; Vanderbilt University School of Medicine; Nashville TN
| | - Richard D. Lescallette
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - Donald H. Arnold
- Division of Emergency Medicine; Center for Asthma Research; Vanderbilt University School of Medicine; Nashville TN
| | - Lawrence B. Stack
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
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O'Connor MG, Berg K, Stack LB, Arnold DH. Variability of the Acute Asthma Intensity Research Score in the pediatric emergency department. Ann Allergy Asthma Immunol 2015; 115:244-5. [PMID: 26165745 DOI: 10.1016/j.anai.2015.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/10/2015] [Accepted: 06/11/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Michael Glenn O'Connor
- Pediatric Pulmonary Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - Kathleen Berg
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Lawrence B Stack
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Donald H Arnold
- Emergency Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee
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Arnold DH, O'Connor MG, Hartert TV. Acute Asthma Intensity Research Score: updated performance characteristics for prediction of hospitalization and lung function. Ann Allergy Asthma Immunol 2015; 115:69-70. [PMID: 25890449 DOI: 10.1016/j.anai.2015.03.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/22/2015] [Accepted: 03/24/2015] [Indexed: 12/26/2022]
Affiliation(s)
- Donald H Arnold
- Department of Pediatrics, Division of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - Michael G O'Connor
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Tina V Hartert
- Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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Arnold DH, Gebretsadik T, Moons KGM, Harrell FE, Hartert TV. Development and internal validation of a pediatric acute asthma prediction rule for hospitalization. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2015; 3:228-35. [PMID: 25609324 PMCID: PMC4355052 DOI: 10.1016/j.jaip.2014.09.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 09/18/2014] [Accepted: 09/18/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Clinicians have difficulty predicting need for hospitalization of children with acute asthma exacerbations. OBJECTIVE The objective of this study was to develop and internally validate a multivariable asthma prediction rule (APR) to inform hospitalization decision making in children aged 5-17 years with acute asthma exacerbations. METHODS Between April 2008 and February 2013 we enrolled a prospective cohort of patients aged 5-17 years with asthma who presented to our pediatric emergency department with acute exacerbations. Predictors for APR modeling included 15 demographic characteristics, asthma chronic control measures, and pulmonary examination findings in participants at the time of triage and before treatment. The primary outcome variable for APR modeling was need for hospitalization (length of stay >24 h for those admitted to hospital or relapse for those discharged). A secondary outcome was the hospitalization decision of the clinical team. We used penalized maximum likelihood multiple logistic regression modeling to examine the adjusted association of each predictor variable with the outcome. Backward step-down variable selection techniques were used to yield reduced-form models. RESULTS Data from 928 of 933 participants were used for prediction rule modeling, with median [interquartile range] age 8.8 [6.9, 11.2] years, 61% male, and 59% African-American race. Both full (penalized) and reduced-form models for each outcome calibrated well, with bootstrap-corrected c-indices of 0.74 and 0.73 for need for hospitalization and 0.81 in each case for hospitalization decision. CONCLUSION The APR predicts the need for hospitalization of children with acute asthma exacerbations using predictor variables available at the time of presentation to an emergency department.
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Affiliation(s)
- Donald H Arnold
- Departments of Pediatrics and Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tenn; Center for Asthma & Environmental Sciences Research, Vanderbilt University School of Medicine, Nashville, Tenn.
| | - Tebeb Gebretsadik
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tenn; Center for Asthma & Environmental Sciences Research, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Karel G M Moons
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tenn; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Tina V Hartert
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn; Center for Asthma & Environmental Sciences Research, Vanderbilt University School of Medicine, Nashville, Tenn
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O’Connor MG, Saville BR, Hartert TV, Arnold DH. Treatment variability of asthma exacerbations in a pediatric emergency department using a severity-based management protocol. Clin Pediatr (Phila) 2014; 53:1288-90. [PMID: 24463950 PMCID: PMC4251715 DOI: 10.1177/0009922813520071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Langley EW, Gebretsadik T, Hartert TV, Peebles RS, Arnold DH. Exhaled nitric oxide is associated with severity of pediatric acute asthma exacerbations. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2014; 2:618-20.e1. [PMID: 25213059 PMCID: PMC4163006 DOI: 10.1016/j.jaip.2014.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 04/04/2014] [Accepted: 04/08/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Emily W Langley
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Tebeb Gebretsadik
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Tina V Hartert
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn; Center for Asthma and Environmental Sciences Research, Vanderbilt University School of Medicine, Nashville, Tenn
| | - R Stokes Peebles
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Donald H Arnold
- Center for Asthma and Environmental Sciences Research, Vanderbilt University School of Medicine, Nashville, Tenn; Departments of Pediatrics and Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tenn.
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