1
|
Alkhazali IE, Alrawashdeh A, Hashairi Fauzi M, Nik Ab Rahman NH. Quality Indicators of Pediatric Asthma Care in the Emergency Department; a Systematic Review and Meta-Analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2024; 12:e26. [PMID: 38572217 PMCID: PMC10988188 DOI: 10.22037/aaem.v12i1.2214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Introduction The quality of healthcare for pediatric asthma patients in the emergency department (ED) is of growing importance. This systematic review aimed to identify and describe existing quality indicators (QIs) designed for use in the ED for pediatric asthma care. Methods We systematically searched three main electronic databases in May 2023 for all English-language qualitative and quantitative publications that suggested or described at least one QI related to pediatric asthma care in the ED. Two reviewers independently selected the included studies and extracted data on study characteristics, all relevant QIs reported, and the rates of compliance with these indicators when available. The identified QIs were classified according to Donabedian healthcare quality framework and the Institute of Medicine (IOM) framework. When feasible, we aggregated the compliance rates for the QIs reported in observational studies using random effects models. The quality assessment of the included studies was performed using various Joanna Briggs Institute (JBI) tools. Results We identified twenty studies, including six expert panels, 13 observational studies, and one trial. Together, these studies presented 129 QIs for use in EDs managing pediatric asthma. Among these QIs, 66 were pinpointed by expert panel studies, whereas 63 were derived from observational studies. Within the Donabedian framework, most indicators (86.8%) concentrated on the process of care. In contrast, within the Institute of Medicine (IOM) domain, the predominant focus was on indicators related to effectiveness and safety. Observational studies reported varying compliance rates for the 36 QIs identified in the expert studies. The included studies showed a wide range of bias risks, suggesting potential methodological variances. Conclusions A significant number of QIs in pediatric asthma care have been proposed or documented in literature. Although most of these indicators prioritize the process of care, there is a conspicuous absence of outcome and structure indicators. This meta-analysis uncovered significant disparities in compliance to the identified QIs, highlighting the urgent necessity for targeted interventions to enhance pediatric asthma care in ED.
Collapse
Affiliation(s)
- Islam E. Alkhazali
- School of Medical Sciences, Health Campus, USM, Kubang Kerian, 16150, Malaysia
| | - Ahmad Alrawashdeh
- Department of Allied Medical Sciences, Jordan University of Science and Technology, Irbid Jordan
| | - Mohd Hashairi Fauzi
- Department of Emergency Medicine, School of Medical Sciences, Health Campus, USM, Kubang Kerian, 16150, Malaysia
| | - Nik Hisamuddin Nik Ab Rahman
- Department of Emergency Medicine, School of Medical Sciences, Health Campus, USM, Kubang Kerian, 16150, Malaysia
- Administrative Block, Hospital USM, Health Campus, USM, Kubang Kerian, 16150, Malaysia
| |
Collapse
|
2
|
Valente BCHG, Melo MDCBD, Liu PMF, Gonçalves BAR, Gomes RADS, Martins IG, Oliveira ACPLD, Ferreira ALDCM, Bothrel RG, de Lima Belizário Facury Lasmar LM. High and low-fidelity simulation for respiratory diseases pediatric training: a prospective and randomized study. J Pediatr (Rio J) 2023; 99:521-528. [PMID: 37244290 PMCID: PMC10492141 DOI: 10.1016/j.jped.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/29/2023] Open
Abstract
OBJECTIVE To compare high and low-fidelity simulations for the recognition of respiratory distress and failure in urgency and emergency pediatric scenarios. METHODS 70 fourth-year medical students were randomly distributed in high and low-fidelity groups and simulated different types of respiratory problems. Theory tests, performance checklists, and satisfaction and self-confidence questionnaires were used in the assessment. Face-to-face simulation and memory retention was applied. The statistics were evaluated by averages and quartiles, Kappa, and generalized estimating equations. The p-value was considered 0.05. RESULTS In the theory test there was an increase in scores in both methodologies (p < 0.001); in memory retention (p = 0.043) and at the end of the process the high-fidelity group had better results. The performance in the practical checklists was better after the second simulation (p > 0,05). The high-fidelity group felt more challenged in both phases (p = 0.042; p = 0.018) and showed greater self-confidence to recognize changes in clinical conditions and in memory retention (p = 0.050). The same group, in relation to the hypothetical real patient to be treated in the future, felt better confident to recognize respiratory distress and failure (p = 0.008; p = 0.004), and better prepared to make a systematic clinical evaluation of the patient in memory retention (p = 0.016). CONCLUSION The two levels of simulations enhance diagnostic skills. High fidelity improves knowledge, leads the student to feel more challenged and more self-confident in recognizing the severity of the clinical case, including memory retention, and showed benefits regarding self-confidence in recognizing respiratory distress and failure in pediatric cases.
Collapse
Affiliation(s)
| | - Maria do Carmo Barros de Melo
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Departamento de Pediatria, Belo Horizonte, Minas Gerais, Brazil
| | - Priscila Menezes Ferri Liu
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Departamento de Pediatria, Belo Horizonte, Minas Gerais, Brazil
| | | | | | - Isadora Guimarães Martins
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Estudante de Medicina Belo Horizonte, Minas Gerais, Brazil
| | | | | | - Rafaella Garcia Bothrel
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Estudante de Medicina Belo Horizonte, Minas Gerais, Brazil
| | | |
Collapse
|
3
|
Reyes MA, Etinger V, Hronek C, Hall M, Davidson A, Mangione-Smith R, Kaiser SV, Parikh K. Pediatric Respiratory Illnesses: An Update on Achievable Benchmarks of Care. Pediatrics 2023; 152:e2022058389. [PMID: 37403624 DOI: 10.1542/peds.2022-058389] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric respiratory illnesses (PRI): asthma, bronchiolitis, pneumonia, croup, and influenza are leading causes of pediatric hospitalizations, and emergency department (ED) visits in the United States. There is a lack of standardized measures to assess the quality of hospital care delivered for these conditions. We aimed to develop a measure set for automated data extraction from administrative data sets and evaluate its performance including updated achievable benchmarks of care (ABC). METHODS A multidisciplinary subject-matter experts team selected quality measures from multiple sources. The measure set was applied to the Public Health Information System database (Children's Hospital Association, Lenexa, KS) to cohorts of ED visits and hospitalizations from 2017 to 2019. ABC for pertinent measures and performance gaps of mean values from the ABC were estimated. ABC were compared with previous reports. RESULTS The measure set: PRI report includes a total of 94 quality measures. The study cohort included 984 337 episodes of care, and 82.3% were discharged from the ED. Measures with low performance included bronchodilators (19.7%) and chest x-rays (14.4%) for bronchiolitis in the ED. These indicators were (34.6%) and (29.5%) in the hospitalized cohort. In pneumonia, there was a 57.3% use of narrow spectrum antibiotics. In general, compared with previous reports, there was improvement toward optimal performance for the ABCs. CONCLUSIONS The PRI report provides performance data including ABC and identifies performance gaps in the quality of care for common respiratory illnesses. Future directions include examining health inequities, and understanding and addressing the effects of the coronavirus disease 2019 pandemic on care quality.
Collapse
Affiliation(s)
- Mario A Reyes
- Division of Hospital Medicine, Department of Pediatrics, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine
| | - Veronica Etinger
- Division of Hospital Medicine, Department of Pediatrics, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine
| | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | | | | | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California
| | - Kavita Parikh
- Children's National Hospital, Washington, District of Columbia
| |
Collapse
|
4
|
Magrelli S, Valentini P, De Rose C, Morello R, Buonsenso D. Classification of Lung Disease in Children by Using Lung Ultrasound Images and Deep Convolutional Neural Network. Front Physiol 2021; 12:693448. [PMID: 34512375 PMCID: PMC8432935 DOI: 10.3389/fphys.2021.693448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/05/2021] [Indexed: 01/12/2023] Open
Abstract
Bronchiolitis is the most common cause of hospitalization of children in the first year of life and pneumonia is the leading cause of infant mortality worldwide. Lung ultrasound technology (LUS) is a novel imaging diagnostic tool for the early detection of respiratory distress and offers several advantages due to its low-cost, relative safety, portability, and easy repeatability. More precise and efficient diagnostic and therapeutic strategies are needed. Deep-learning-based computer-aided diagnosis (CADx) systems, using chest X-ray images, have recently demonstrated their potential as a screening tool for pulmonary disease (such as COVID-19 pneumonia). We present the first computer-aided diagnostic scheme for LUS images of pulmonary diseases in children. In this study, we trained from scratch four state-of-the-art deep-learning models (VGG19, Xception, Inception-v3 and Inception-ResNet-v2) for detecting children with bronchiolitis and pneumonia. In our experiments we used a data set consisting of 5,907 images from 33 healthy infants, 3,286 images from 22 infants with bronchiolitis, and 4,769 images from 7 children suffering from bacterial pneumonia. Using four-fold cross-validation, we implemented one binary classification (healthy vs. bronchiolitis) and one three-class classification (healthy vs. bronchiolitis vs. bacterial pneumonia) out of three classes. Affine transformations were applied for data augmentation. Hyperparameters were optimized for the learning rate, dropout regularization, batch size, and epoch iteration. The Inception-ResNet-v2 model provides the highest classification performance, when compared with the other models used on test sets: for healthy vs. bronchiolitis, it provides 97.75% accuracy, 97.75% sensitivity, and 97% specificity whereas for healthy vs. bronchiolitis vs. bacterial pneumonia, the Inception-v3 model provides the best results with 91.5% accuracy, 91.5% sensitivity, and 95.86% specificity. We performed a gradient-weighted class activation mapping (Grad-CAM) visualization and the results were qualitatively evaluated by a pediatrician expert in LUS imaging: heatmaps highlight areas containing diagnostic-relevant LUS imaging-artifacts, e.g., A-, B-, pleural-lines, and consolidations. These complex patterns are automatically learnt from the data, thus avoiding hand-crafted features usage. By using LUS imaging, the proposed framework might aid in the development of an accessible and rapid decision support-method for diagnosing pulmonary diseases in children using LUS imaging.
Collapse
Affiliation(s)
| | - Piero Valentini
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Global Health Research Institute, Istituto di Igiene, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cristina De Rose
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rosa Morello
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Global Health Research Institute, Istituto di Igiene, Università Cattolica del Sacro Cuore, Rome, Italy.,Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
5
|
Abstract
BACKGROUND Croup is an acute viral respiratory infection with upper airway mucosal inflammation that may cause respiratory distress. Most cases are mild. Moderate to severe croup may require treatment with corticosteroids (the benefits of which are often delayed) and nebulised epinephrine (adrenaline) (the benefits of which may be short-lived and which can cause dose-related adverse effects including tachycardia, arrhythmias, and hypertension). Rarely, croup results in respiratory failure necessitating emergency intubation and ventilation. A mixture of helium and oxygen (heliox) may prevent morbidity and mortality in ventilated neonates by reducing the viscosity of the inhaled air. It is currently used during emergency transport of children with severe croup. Anecdotal evidence suggests that it relieves respiratory distress. This review updates versions published in 2010, 2013, and 2018. OBJECTIVES To examine the effect of heliox compared to oxygen or other active interventions, placebo, or no treatment on relieving signs and symptoms in children with croup as determined by a croup score and rates of admission and intubation. SEARCH METHODS We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE, Embase, CINAHL, Web of Science, and LILACS, on 15 April 2021. We also searched the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch/) and ClinicalTrials.gov (clinicaltrials.gov) on 15 April 2021. We contacted the British Oxygen Company, a leading supplier of heliox. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing the effect of heliox in comparison with placebo, no treatment, or any active intervention(s) in children with croup. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Data that could not be pooled for statistical analysis were reported descriptively. MAIN RESULTS We included 3 RCTs involving a total of 91 children aged between 6 months and 4 years. Study duration was from 7 to 16 months, and all studies were conducted in emergency departments. Two studies were conducted in the USA and one in Spain. Heliox was administered as a mixture of 70% heliox and 30% oxygen. Risk of bias was low in two studies and high in one study because of its open-label design. We did not identify any new trials for this 2021 update. One study of 15 children with mild croup compared heliox with 30% humidified oxygen administered for 20 minutes. There may be no difference in croup score changes between groups at 20 minutes (mean difference (MD) -0.83, 95% confidence interval (CI) -2.36 to 0.70) (Westley croup score, scale range 0 to 16). The mean croup score at 20 minutes postintervention may not differ between groups (MD -0.57, 95% CI -1.46 to 0.32). There may be no difference between groups in mean respiratory rate (MD 6.40, 95% CI -1.38 to 14.18) and mean heart rate (MD 14.50, 95% CI -8.49 to 37.49) at 20 minutes. The evidence for all outcomes in this comparison was of low certainty, downgraded for serious imprecision. All children were discharged, but information on hospitalisation, intubation, or re-presenting to emergency departments was not reported. In another study, 47 children with moderate croup received one dose of oral dexamethasone (0.3 mg/kg) with either heliox for 60 minutes or no treatment. Heliox may slightly improve Taussig croup scores (scale range 0 to 15) at 60 minutes postintervention (MD -1.10, 95% CI -1.96 to -0.24), but there may be no difference between groups at 120 minutes (MD -0.70, 95% CI -1.56 to 0.16). Children treated with heliox may have lower mean Taussig croup scores at 60 minutes (MD -1.11, 95% CI -2.05 to -0.17) but not at 120 minutes (MD -0.71, 95% CI -1.72 to 0.30). Children treated with heliox may have lower mean respiratory rates at 60 minutes (MD -4.94, 95% CI -9.66 to -0.22), but there may be no difference at 120 minutes (MD -3.17, 95% CI -7.83 to 1.49). There may be a difference in hospitalisation rates between groups (odds ratio 0.46, 95% CI 0.04 to 5.41). We assessed the evidence for all outcomes in this comparison as of low certainty, downgraded due to imprecision and high risk of bias related to an open-label design. Information on heart rate and intubation was not reported. In the third study, 29 children with moderate to severe croup all received continuous cool mist and intramuscular dexamethasone (0.6 mg/kg). They were then randomised to receive either heliox (given as a mixture of 70% helium and 30% oxygen) plus one to two doses of nebulised saline or 100% oxygen plus nebulised epinephrine (adrenaline), with gas therapy administered continuously for three hours. Heliox may slightly improve croup scores at 90 minutes postintervention, but may result in little or no difference overall using repeated-measures analysis. We assessed the evidence for all outcomes in this comparison as of low certainty, downgraded due to high risk of bias related to inadequate reporting. Information on hospitalisation or re-presenting to the emergency department was not reported. The included studies did not report on adverse events, intensive care admissions, or parental anxiety. We could not pool the available data because each comparison included data from only one study. AUTHORS' CONCLUSIONS Given the very limited available evidence, uncertainty remains regarding the effectiveness and safety of heliox. Heliox may not be more effective than 30% humidified oxygen for children with mild croup, but may be beneficial in the short term for children with moderate croup treated with dexamethasone. The effect of heliox may be similar to 100% oxygen given with one or two doses of adrenaline. Adverse events were not reported, and it is unclear if these were monitored in the included studies. Adequately powered RCTs comparing heliox with standard treatments are needed to further assess the role of heliox in the treatment of children with moderate to severe croup.
Collapse
Affiliation(s)
- Irene Moraa
- School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - Nancy Sturman
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Treasure M McGuire
- School of Pharmacy, The University of Queensland, Brisbane, Australia
- Mater Pharmacy Services (Practice & Development), Mater Health Services, South Brisbane, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Mieke L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| |
Collapse
|
6
|
Alharbi AS, Yousef AA, Alharbi SA, Al-Shamrani A, Alqwaiee MM, Almeziny M, Said YS, Alshehri SA, Alotaibi FN, Mosalli R, Alawam KA, Alsaadi MM. Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus. Ann Thorac Med 2021; 16:188-218. [PMID: 34012486 PMCID: PMC8109687 DOI: 10.4103/atm.atm_74_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/14/2021] [Indexed: 11/27/2022] Open
Abstract
The Saudi Pediatric Pulmonology Association (SPPA) is a subsidiary of the Saudi Thoracic Society (STS), which consists of a group of Saudi experts with well-respected academic and clinical backgrounds in the fields of asthma and other respiratory diseases. The SPPA Expert Panel realized the need to draw up a clear, simple to understand, and easy to use guidance regarding the application of different aerosol therapies in respiratory diseases in children, due to the high prevalence and high economic burden of these diseases in Saudi Arabia. This statement was developed based on the available literature, new evidence, and experts' practice to come up with such consensuses about the usage of different aerosol therapies for the management of respiratory diseases in children (asthma and nonasthma) in different patient settings, including outpatient, emergency room, intensive care unit, and inpatient settings. For this purpose, SPPA has initiated and formed a national committee which consists of experts from concerned specialties (pediatric pulmonology, pediatric emergency, clinical pharmacology, pediatric respiratory therapy, as well as pediatric and neonatal intensive care). These committee members are from different healthcare sectors in Saudi Arabia (Ministry of Health, Ministry of Defence, Ministry of Education, and private healthcare sector). In addition to that, this committee is representing different regions in Saudi Arabia (Eastern, Central, and Western region). The subject was divided into several topics which were then assigned to at least two experts. The authors searched the literature according to their own strategies without central literature review. To achieve consensus, draft reports and recommendations were reviewed and voted on by the whole panel.
Collapse
Affiliation(s)
- Adel S. Alharbi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Department of Pediatrics, King Fahd Hospital of the University, Khobar, Saudi Arabia
| | - Saleh A. Alharbi
- Department of Pediatrics, Umm Al-Qura University, Mecca, Saudi Arabia
- Department of Pediatrics, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Abdullah Al-Shamrani
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mansour M. Alqwaiee
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mohammed Almeziny
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Yazan S. Said
- Department of Pediatrics, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Saleh Ali Alshehri
- Department of Emergency, Pediatric Emergency Division, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Faisal N. Alotaibi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defence, Riyadh, Saudi Arabia
| | - Rafat Mosalli
- Department of Pediatrics, Umm Al Qura University, Makkah, Saudi Arabia
- Department of Pediatrics, International Medical Center, Jeddah, Saudi Arabia
| | - Khaled Ali Alawam
- Department of Respiratory Therapy Sciences, Inaya Medical College, Riyadh, Saudi Arabia
| | - Muslim M. Alsaadi
- Department of Pediatrics, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
7
|
Hanna J, Brauer PR, Morse E, Berson E, Mehra S. Epidemiological analysis of croup in the emergency department using two national datasets. Int J Pediatr Otorhinolaryngol 2019; 126:109641. [PMID: 31442871 DOI: 10.1016/j.ijporl.2019.109641] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 07/11/2019] [Accepted: 08/09/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To characterize cases of croup presenting to emergency departments (EDs) nationwide, analyze trends, and determine readmission rates. METHODS Retrospective review of the Nationwide Emergency Department Sample (2007-2014) and the National Hospital Ambulatory Medical Care Survey (2008-2015). RESULTS Both databases provided similar descriptive statistics. Annual mean of 352,388 (weighted) cases in the National Emergency Department Sample (1.35% of ED cases). Average age and male:female ratio 2.50 years and 1.95:1, respectively. Peak incidence was in autumn (October = 13.7%) with troughs in the summer (July = 3.7%). 21.3% received nebulizers, <1% laryngoscopic or airway procedures, 75.1% steroids, and 13.3% antibiotics. Of the patients receiving antibiotics, 16.0% had isolated croup. 3.0% of cases were admitted to the hospital. No trend was identified in the incidence of croup, mean age, or antibiotic and steroid usage. Hospital admission rates decreased (4.0%-2.3%) and nebulizer usage increased (14.6%-27.5%; p < 0.05). 5% of patients represented repeat admissions (were seen within 72 h prior). CONCLUSIONS Croup imposes a significant burden on the ED. Although hospital admissions decreased, annual incidence in the ED remained stable. The majority of cases are in males less than three years old, and 5.0% of patients represented readmissions. Only three-quarters received glucocorticoids despite the proven benefits, including reducing readmission rates. Antibiotic usage was high, with a large number representing potential cases of inappropriate antibiotic use.
Collapse
Affiliation(s)
- Jonathan Hanna
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA
| | - Philip R Brauer
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA
| | - Elliot Morse
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA
| | - Elisa Berson
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA
| | - Saral Mehra
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA; Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, Yale-New Haven Hospital, Yale Cancer Center, New Haven, CT, USA.
| |
Collapse
|
8
|
Abstract
BACKGROUND Croup is an acute viral respiratory infection with upper airway mucosal inflammation that may cause respiratory distress. Most cases are mild. Moderate to severe croup may require treatment with corticosteroids (from which benefits are often delayed) and nebulised epinephrine (adrenaline) (which may be short-lived and can cause dose-related adverse effects including tachycardia, arrhythmias, and hypertension). Rarely, croup results in respiratory failure necessitating emergency intubation and ventilation.A mixture of helium and oxygen (heliox) may prevent morbidity and mortality in ventilated neonates by reducing the viscosity of the inhaled air. It is currently used during emergency transport of children with severe croup. Anecdotal evidence suggests that it relieves respiratory distress.This review updates versions published in 2010 and 2013. OBJECTIVES To examine the effect of heliox compared to oxygen or other active interventions, placebo, or no treatment, on relieving signs and symptoms in children with croup as determined by a croup score and rates of admission and intubation. SEARCH METHODS We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE; Embase; CINAHL; Web of Science; and LILACS in January and February 2018. We also searched the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch/) and ClinicalTrials.gov (clinicaltrials.gov) on 8 February 2018. We contacted British Oxygen Company, a leading supplier of heliox (BOC Australia 2017). SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing the effect of heliox in comparison with placebo or any active intervention(s) in children with croup. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We reported data that could not be pooled for statistical analysis descriptively. MAIN RESULTS We included 3 RCTs with 91 children aged between 6 months and 4 years. Study duration was from 7 to 16 months; all studies were conducted in emergency departments in the USA (two studies) and Spain. Heliox was administered as a mixture of 70% heliox and 30% oxygen. Risk of bias was low in two studies and high in one study due to an open-label design. We added no new trials for this update.One study of 15 children with mild croup compared heliox with 30% humidified oxygen administered for 20 minutes. There may be no difference in croup score changes between groups at 20 minutes (mean difference (MD) -0.83, 95% confidence interval (CI) -2.36 to 0.70). The mean croup score at 20 minutes postintervention may not differ between groups (MD -0.57, 95% CI -1.46 to 0.32). There may be no difference between groups in mean respiratory rate (MD 6.40, 95% CI -1.38 to 14.18) and mean heart rate (MD 14.50, 95% CI -8.49 to 37.49) at 20 minutes. The evidence for all outcomes in this comparison was of low quality, downgraded for serious imprecision. All children were discharged, but information on hospitalisation, intubation, or re-presenting to emergency departments was not reported.In another study, 47 children with moderate croup received one dose of oral dexamethasone (0.3 mg/kg) with either heliox for 60 minutes or no treatment. Heliox may slightly improve croup scores at 60 minutes postintervention (MD -1.10, 95% CI -1.96 to -0.24), but there may be no difference between groups at 120 minutes (MD -0.70, 95% CI -4.86 to 3.46). Children treated with heliox may have lower mean Taussig croup scores at 60 minutes (MD -1.11, 95% CI -2.05 to -0.17) but not at 120 minutes (MD -0.71, 95% CI -1.72 to 0.30). Children treated with heliox may have lower mean respiratory rates at 60 minutes (MD -4.94, 95% CI -9.66 to -0.22), but there may be no difference at 120 minutes (MD -3.17, 95% CI -7.83 to 1.49). There may be no difference in hospitalisation rates between groups (OR 0.46, 95% CI 0.04 to 5.41). We assessed the evidence for all outcomes in this comparison as of low quality, downgraded due to imprecision and high risk of bias related to open-label design. Information on heart rate and intubation was not reported.In the third study, 29 children with moderate to severe croup received intramuscular dexamethasone (0.6 mg/kg) and either heliox with one to two doses of nebulised saline, or 100% oxygen with one to two doses of adrenaline for three hours. Heliox may slightly improve croup scores at 90 minutes postintervention, but may have little or no difference overall using repeated measures analysis. We assessed the evidence for all outcomes in this comparison as of low quality, downgraded due to high risk of bias related to inadequate reporting. Information on hospitalisation or re-presenting to the emergency department was not reported.The included studies did not report on adverse events, intensive care admissions, or parental anxiety.We could not pool the available data because each comparison included data from only one study. AUTHORS' CONCLUSIONS Due to very limited evidence, uncertainty remains about the effectiveness and safety of heliox. Heliox may not be more effective than 30% humidified oxygen for children with mild croup, but may be beneficial in the short term for children with moderate to severe croup treated with dexamethasone. The effect may be similar to 100% oxygen given with one or two doses of adrenaline. Adverse events were not reported, and it is unclear if these were monitored in the included studies. Adequately powered RCTs comparing heliox with standard treatments are needed to further assess the role of heliox in the treatment of children with moderate to severe croup.
Collapse
Affiliation(s)
- Irene Moraa
- The University of QueenslandSchool of Pharmacy20 Cornwall StreetBrisbaneQueenslandAustralia
| | - Nancy Sturman
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineHerstonBrisbaneQueenslandAustralia4029
| | - Treasure M McGuire
- The University of QueenslandSchool of Pharmacy20 Cornwall StreetBrisbaneQueenslandAustralia
- Mater Health ServicesMater Pharmacy Services (Practice & Development)South BrisbaneAustralia4101
- Bond UniversityFaculty of Health Sciences and MedicineUniversity Drive, RobinaGold CoastQueenslandAustralia4229
| | - Mieke L van Driel
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineHerstonBrisbaneQueenslandAustralia4029
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia4229
- Ghent UniversityDepartment of Family Medicine and Primary Health CareCampus UZ 6K3, Corneel Heymanslaan 10GhentBelgium9000
| | | |
Collapse
|
9
|
Buonsenso D, Supino MC, Giglioni E, Battaglia M, Mesturino A, Scateni S, Scialanga B, Reale A, Musolino AMC. Point of care diaphragm ultrasound in infants with bronchiolitis: A prospective study. Pediatr Pulmonol 2018; 53:778-786. [PMID: 29578644 DOI: 10.1002/ppul.23993] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/01/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Bronchiolitis is the most common reason for hospitalization of children worldwide. Many scoring systems have been developed to quantify respiratory distress and predict outcome, but none of them have been validated. We hypothesized that the ultrasound evaluation of the diaphragm could quantify respiratory distress and therefore we correlated the ultrasound diaphragm parameters with outcome. METHODS Prospective study of infants with bronchiolitis (1-12 months) evaluated in a pediatric emergency department. Ultrasonography examinations of the diaphragm was performed (diaphragm excursion [DE], inspiratory excursion [IS], inspiratory/expiratory relationship [I/E], and thickness at end-expiration [TEE] and at end-inspiration [TEI]; thickening fraction [TF]). RESULTS We evaluated 61 infants, 50.8 % males. Mean TF was 47% (IQR 28.6-64.7), mean I/E 0.47 (± 0.15), mean DE 10.39 ± 4 mm. There was a linear correlation between TF and oxygen saturation at first evaluation (P = 0.006, r = 0.392). All children with lower values of TF required HFNC and one of them required CPAP. A higher IS was associated with the future need of respiratory support during admission (P = 0.007). IS correlated with the hours of oxygen delivery needed (P = 0.032, r = 0.422). TEI (t = 3.701, P = 0.002) was found to be main predictor of hours of oxygen delivery needed. CONCLUSION This study described ultrasound diaphragmatic values of previously healthy infants with bronchiolitis. DE, IS, and TEI correlated with outcome. If confirmed in larger studies, bedside ultrasound semiology of the diaphragm can be a new objective tool for the evaluation and outcome prediction of infants with bronchiolitis.
Collapse
Affiliation(s)
- Danilo Buonsenso
- Department of Pediatric Emergency, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Institute of Pediatrics, Catholic University of Sacred Heart, Rome, Italy
| | - Maria C Supino
- Department of Pediatrics, Sapienza University, S. Andrea Hospital, Roma, Italy
| | - Emanuele Giglioni
- Department of Pediatric Emergency, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Massimo Battaglia
- Department of Pediatric Emergency, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessia Mesturino
- Department of Pediatric Emergency, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Scateni
- Department of Pediatric Emergency, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Barbara Scialanga
- Department of Pediatric Emergency, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonino Reale
- Department of Pediatric Emergency, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Anna M C Musolino
- Department of Pediatric Emergency, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| |
Collapse
|
10
|
Wilkinson M, King B, Iyer S, Higginbotham E, Wallace A, Hovinga C, Allen C. Comparison of a rapid albuterol pathway with a standard pathway for the treatment of children with a moderate to severe asthma exacerbation in the emergency department. J Asthma 2017; 55:244-251. [PMID: 28548898 DOI: 10.1080/02770903.2017.1323920] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The objective of this study was to determine if a rapid albuterol delivery pathway with a breath-enhanced nebulizer can reduce emergency department (ED) length of stay (LOS), while maintaining admission rates and side effects, when compared to a traditional asthma pathway with a standard jet nebulizer. METHODS Children aged 3-18 presenting to a large urban pediatric ED for asthma were enrolled if they were determined by pediatric asthma score to have a moderate to severe exacerbation. Subjects were randomized to either a standard treatment arm where they received up to 2 continuous albuterol nebulizations, or a rapid albuterol arm where they received up to 4 rapid albuterol treatments with a breath-enhanced nebulizer, depending on severity scoring. The primary endpoint was ED LOS from enrollment until disposition decision. Asthma scores, albuterol dose, side effects, and return visits were also recorded. RESULTS A total of 50 subjects were enrolled (25 in each arm). The study LOS was shorter in the rapid albuterol group (118 vs. 163 minutes, p = 0.0002). When total ED LOS was analyzed, the difference was no longer statistically significant (192 vs. 203 minutes, p = 0.65). There were no statistically significant differences with respect to admission rates, asthma score changes, side effects, or return visits. CONCLUSION A rapid albuterol treatment pathway that utilizes a breath-enhanced nebulizer is an effective alternative to traditional pathways that utilize continuous nebulizations for children with moderate to severe asthma exacerbations in the ED.
Collapse
Affiliation(s)
- Matthew Wilkinson
- a Department of Pediatrics , University of Texas at Austin Dell Medical School , Austin , TX , USA.,b Dell Children's Medical Center of Central Texas, Pediatric Emergency Medicine , Austin , TX , USA
| | - Ben King
- c Seton Healthcare Family , Stroke Institute , Austin , TX , USA
| | - Sujit Iyer
- a Department of Pediatrics , University of Texas at Austin Dell Medical School , Austin , TX , USA.,b Dell Children's Medical Center of Central Texas, Pediatric Emergency Medicine , Austin , TX , USA
| | - Eric Higginbotham
- a Department of Pediatrics , University of Texas at Austin Dell Medical School , Austin , TX , USA.,b Dell Children's Medical Center of Central Texas, Pediatric Emergency Medicine , Austin , TX , USA
| | - Anna Wallace
- b Dell Children's Medical Center of Central Texas, Pediatric Emergency Medicine , Austin , TX , USA
| | - Collin Hovinga
- d Seton Healthcare Family , Research Enterprise , Austin , TX , USA.,e College of Pharmacy , University of Texas at Austin , Austin , TX , USA
| | - Coburn Allen
- a Department of Pediatrics , University of Texas at Austin Dell Medical School , Austin , TX , USA.,b Dell Children's Medical Center of Central Texas, Pediatric Emergency Medicine , Austin , TX , USA
| |
Collapse
|
11
|
The utility of lung ultrasound in evaluation of infants with suspected bronchiolitis. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2016.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
|
12
|
Pinto JM, Schairer JL, Petrova A. Duration of Hospitalization in Association with Type of Inhalation Therapy Used in the Management of Children with Nonsevere, Acute Bronchiolitis. Pediatr Neonatol 2016; 57:140-4. [PMID: 26464183 DOI: 10.1016/j.pedneo.2015.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 03/17/2015] [Accepted: 04/16/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Acute bronchiolitis is one of the main respiratory emergencies in young children. Although supportive therapy is recommended, substantial inconsistency in the clinical usage of inhaled treatments has been reported. In the present study, we evaluated the association between different types of nebulized therapies in clinical practice and the length of stay (LOS) of young children hospitalized with nonsevere bronchiolitis. METHODS Medical records of 195 patients with bronchiolitis, without evidence of pneumonia or congenital/chronic respiratory conditions, were stratified with respect to the type of inhalation therapy received: nebulized albuterol (Group 1, n = 53), nebulized albuterol with 3% saline (Group 2, n = 38), nebulized 3% saline alone (Group 3, n = 33), or no inhaled treatment (Group 4, n = 71). Duration of hospital stay was reported with respect to the type of inhalation therapy received after controlling for variability in patient age (months), oxygen saturation, respiratory score, and use of other treatments (antibiotics, oxygen supplementation, and/or corticosteroids). LOS is presented in terms of mean and 95% confidence interval (95% CI). RESULTS The groups were similar except for differences in the mean level of oxygen saturation, respiratory score, and corticosteroid use. Children in Group 4 had the lowest mean respiratory score due to a lesser prevalence of wheezing and/or retractions than in other groups. The LOS for children in Groups 1 and 4 was shorter (43.2 hours, 95% CI 34.9-51.3, and 44.1 hours, 95% CI 37.3-51.0, respectively) than in Groups 2 and 3 (72 hours, 95% CI 62.1-81.6, and 65.1 hours, 95% CI 54.7-75.6, respectively) (p < 0.02). The mean LOS in each group did not change significantly after adjustment for covariants. CONCLUSION Prolonged hospitalization of children younger than 2 years with acute, nonsevere bronchiolitis is associated with administration of nebulized 3% saline, independent of age, clinical presentation of disease, or inclusion of other treatments in their management.
Collapse
Affiliation(s)
- Jamie M Pinto
- Department of Pediatrics, Jersey Shore University Medical Center, Neptune, NJ, USA.
| | - Janet L Schairer
- Department of Pediatrics, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Anna Petrova
- Department of Pediatrics, Jersey Shore University Medical Center, Neptune, NJ, USA; Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| |
Collapse
|
13
|
Vranić DN, Jurković J, Jeličić J, Balenović A, Stipančić G, Čuković-Bagić I. Medical Emergencies in Pediatric Dentistry. Acta Stomatol Croat 2016; 50:72-80. [PMID: 27688429 PMCID: PMC5017275 DOI: 10.15644/asc50/1/10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 03/05/2016] [Indexed: 10/31/2022] Open
Abstract
Medical emergencies that are life threatening can occur in dental practice. Complications may arise because of an underlying disease or a reaction to medication. Reactions to medications may be allergic and toxic. The most common reactions are toxic reactions to local anesthetics, whereas allergies occur mainly as a consequence of the application of antibiotics, usually penicillin. In response to stress, vasovagal syncope typically occurs. Other causes may be related to an underlying disease-specific pathology (such as acute asthma attack, diabetic ketoacidosis, hypoglycemia, or seizures) or accidents (aspiration of a foreign body causing obstruction of the respiratory system). For all the above conditions, guidelines have been established that need to be known. If complications occur or necessary measures are not taken, it can lead to cardiac and respiratory arrest. Therefore, cardiopulmonary resuscitation is needed. All procedures and dosages should be adapted to the age of the child.
Collapse
Affiliation(s)
- Dubravka Negovetić Vranić
- Department of Pediatric and Preventive Dentistry, School of Dental Medicine, University of Zagreb, Croatia
| | | | | | | | - Gordana Stipančić
- Paediatric Department, School of Dental Medicine, University of Zagreb, Croatia
| | - Ivana Čuković-Bagić
- Department of Pediatric and Preventive Dentistry, School of Dental Medicine, University of Zagreb, Croatia
| |
Collapse
|
14
|
Cronin JJ, McCoy S, Kennedy U, An Fhailí SN, Wakai A, Hayden J, Crispino G, Barrett MJ, Walsh S, O'Sullivan R. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Ann Emerg Med 2015; 67:593-601.e3. [PMID: 26460983 DOI: 10.1016/j.annemergmed.2015.08.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 06/18/2015] [Accepted: 07/31/2015] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE In acute exacerbations of asthma in children, corticosteroids reduce relapses, subsequent hospital admission, and the need for ß2-agonist bronchodilators. Prednisolone is the most commonly used corticosteroid, but prolonged treatment course, vomiting, and a bitter taste may reduce patient compliance. Dexamethasone has a longer half-life and has been used safely in other acute pediatric conditions. We examine whether a single dose of oral dexamethasone is noninferior to prednisolone in the emergency department (ED) treatment of asthma exacerbations in children, as measured by the Pediatric Respiratory Assessment Measure (PRAM) at day 4. METHODS We conducted a randomized, open-label, noninferiority trial comparing oral dexamethasone (single dose of 0.3 mg/kg) with prednisolone (1 mg/kg per day for 3 days) in patients aged 2 to 16 years and with a known diagnosis of asthma or at least 1 previous episode of ß2-agonist-responsive wheeze who presented to a tertiary pediatric ED. The primary outcome measure was the mean PRAM score (range of 0 to 12 points) performed on day 4. Secondary outcome measures included requirement for further steroids, vomiting of study medication, hospital admission, and unscheduled return visits to a health care practitioner within 14 days. RESULTS There were 245 enrollments involving 226 patients. There was no difference in mean PRAM scores at day 4 between the dexamethasone and prednisolone groups (0.91 versus 0.91; absolute difference 0.005; 95% CI -0.35 to 0.34). Fourteen patients vomited at least 1 dose of prednisolone compared with no patients in the dexamethasone group. Sixteen children (13.1%) in the dexamethasone group received further systemic steroids within 14 days after trial enrollment compared with 5 (4.2%) in the prednisolone group (absolute difference 8.9%; 95% CI 1.9% to 16.0%). There was no significant difference between the groups in hospital admission rates or the number of unscheduled return visits to a health care practitioner. CONCLUSION In children with acute exacerbations of asthma, a single dose of oral dexamethasone (0.3 mg/kg) is noninferior to a 3-day course of oral prednisolone (1 mg/kg per day) as measured by the mean PRAM score on day 4.
Collapse
Affiliation(s)
- John J Cronin
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland; Department of Emergency Medicine, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
| | - Siobhan McCoy
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland; Department of Emergency Medicine, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
| | - Una Kennedy
- Department of Emergency Medicine, St James's Hospital, Dublin 8, Ireland
| | - Sinéad Nic An Fhailí
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland
| | - Abel Wakai
- Emergency Care Research Unit, Division of Population Health Sciences, Royal College of Surgeons, Dublin 2, Ireland
| | - John Hayden
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland
| | | | - Michael J Barrett
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland; Department of Emergency Medicine, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland; Department of Paediatrics, University College Dublin, Belfield, Dublin 4, Ireland
| | - Sean Walsh
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland; Department of Emergency Medicine, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
| | - Ronan O'Sullivan
- Paediatric Emergency Research Unit, National Children's Research Centre, Dublin 12, Ireland; Department of Emergency Medicine, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland; Department of Paediatrics, University College Dublin, Belfield, Dublin 4, Ireland; School of Medicine, University College Cork, Cork, Ireland.
| |
Collapse
|
15
|
Yang NH, Dharmar M, Yoo BK, Leigh JP, Kuppermann N, Romano PS, Nesbitt TS, Marcin JP. Economic Evaluation of Pediatric Telemedicine Consultations to Rural Emergency Departments. Med Decis Making 2015; 35:773-783. [PMID: 25952744 PMCID: PMC9727838 DOI: 10.1177/0272989x15584916] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 03/13/2015] [Indexed: 11/04/2023]
Abstract
BACKGROUND Comprehensive economic evaluations have not been conducted on telemedicine consultations to children in rural emergency departments (EDs). OBJECTIVE We conducted an economic evaluation to estimate the cost, effectiveness, and return on investment (ROI) of telemedicine consultations provided to health care providers of acutely ill and injured children in rural EDs compared with telephone consultations from a health care payer prospective. METHODS We built a decision model with parameters from primary programmatic data, national data, and the literature. We performed a base-case cost-effectiveness analysis (CEA), a probabilistic CEA with Monte Carlo simulation, and ROI estimation when CEA suggested cost-saving. The CEA was based on program effectiveness, derived from transfer decisions following telemedicine and telephone consultations. RESULTS The average cost for a telemedicine consultation was $3641 per child/ED/year in 2013 US dollars. Telemedicine consultations resulted in 31% fewer patient transfers compared with telephone consultations and a cost reduction of $4662 per child/ED/year. Our probabilistic CEA demonstrated telemedicine consultations were less costly than telephone consultations in 57% of simulation iterations. The ROI was calculated to be 1.28 ($4662/$3641) from the base-case analysis and estimated to be 1.96 from the probabilistic analysis, suggesting a $1.96 return for each dollar invested in telemedicine. Treating 10 acutely ill and injured children at each rural ED with telemedicine resulted in an annual cost-savings of $46,620 per ED. LIMITATIONS Telephone and telemedicine consultations were not randomly assigned, potentially resulting in biased results. CONCLUSIONS From a health care payer perspective, telemedicine consultations to health care providers of acutely ill and injured children presenting to rural EDs are cost-saving (base-case and more than half of Monte Carlo simulation iterations) or cost-effective compared with telephone consultations.
Collapse
Affiliation(s)
- Nikki H Yang
- Department of Pediatrics, University of California, Davis, CA, USA (NHY, MD, NK, PSR, JPM)
| | - Madan Dharmar
- Department of Pediatrics, University of California, Davis, CA, USA (NHY, MD, NK, PSR, JPM)
| | - Byung-Kwang Yoo
- Department of Public Health Sciences, University of California, Davis, CA, USA (BKY, JPL)
| | - J Paul Leigh
- Department of Public Health Sciences, University of California, Davis, CA, USA (BKY, JPL)
| | - Nathan Kuppermann
- Department of Pediatrics, University of California, Davis, CA, USA (NHY, MD, NK, PSR, JPM)
- Department of Emergency Medicine, University of California, Davis, CA, USA (NK)
| | - Patrick S Romano
- Department of Pediatrics, University of California, Davis, CA, USA (NHY, MD, NK, PSR, JPM)
- Department of Internal Medicine, University of California, Davis, CA, USA (PSR)
| | - Thomas S Nesbitt
- Department of Family Practice and Community Medicine, University of California, Davis, CA, USA (TSN)
| | - James P Marcin
- Department of Pediatrics, University of California, Davis, CA, USA (NHY, MD, NK, PSR, JPM)
| |
Collapse
|
16
|
Pediatric emergencies. Crit Care Nurs Clin North Am 2014; 27:105-20. [PMID: 25725540 DOI: 10.1016/j.cnc.2014.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
It is important that pediatric critical care nurses possess a thorough understanding of their patient and be able to provide exceptional care, especially during emergent situations in the operating room. This care is accomplished by assessing the pediatric patient, dosing medications accurately and effectively, and performing effective Pediatric Advanced Life Support. Pediatric patients present with unique anatomy, physiology, and pathophysiology. Emergencies are reviewed according to organ system, with a focus on definition, presentation, pathophysiology, management, and special considerations.
Collapse
|
17
|
Ravaglia C, Poletti V. Recent advances in the management of acute bronchiolitis. F1000PRIME REPORTS 2014; 6:103. [PMID: 25580257 PMCID: PMC4229723 DOI: 10.12703/p6-103] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute bronchiolitis is characterized by acute wheezing in infants or children and is associated with signs or symptoms of respiratory infection; it is rarely symptomatic in adults and the most common etiologic agent is respiratory syncytial virus (RSV). Usually it does not require investigation, treatment is merely supportive and a conservative approach seems adequate in the majority of children, especially for the youngest ones (<3 months); however, clinical scoring systems have been proposed and admission in hospital should be arranged in case of severe disease or a very young age or important comorbidities. Apnea is a very important aspect of the management of young infants with bronchiolitis. This review focuses on the clinical, radiographic, and pathologic characteristics, as well as the recent advances in management of acute bronchiolitis.
Collapse
Affiliation(s)
- Claudia Ravaglia
- Pulmonology Unit, Department of Thoracic DiseasesGB Pierantoni - L Morgagni Hospital, via C. Forlanini 34, 47100 ForlìItaly
| | - Venerino Poletti
- Pulmonology Unit, Department of Thoracic DiseasesGB Pierantoni - L Morgagni Hospital, via C. Forlanini 34, 47100 ForlìItaly
| |
Collapse
|
18
|
Øymar K, Skjerven HO, Mikalsen IB. Acute bronchiolitis in infants, a review. Scand J Trauma Resusc Emerg Med 2014; 22:23. [PMID: 24694087 PMCID: PMC4230018 DOI: 10.1186/1757-7241-22-23] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 03/28/2014] [Indexed: 12/26/2022] Open
Abstract
Acute viral bronchiolitis is one of the most common medical emergency situations in infancy, and physicians caring for acutely ill children will regularly be faced with this condition. In this article we present a summary of the epidemiology, pathophysiology and diagnosis, and focus on guidelines for the treatment of bronchiolitis in infants. The cornerstones of the management of viral bronchiolitis are the administration of oxygen and appropriate fluid therapy, and overall a “minimal handling approach” is recommended. Inhaled adrenaline is commonly used in some countries, but the evidences are sparse. Recently, inhalation with hypertonic saline has been suggested as an optional treatment. When medical treatment fails to stabilize the infants, non-invasive and invasive ventilation may be necessary to prevent and support respiratory failure. It is important that relevant treatment algorithms exist, applicable to all levels of the treatment chain and reflecting local considerations and circumstances.
Collapse
Affiliation(s)
- Knut Øymar
- Department of Paediatrics, Stavanger University Hospital, PO Box 8100, N-4068 Stavanger, Norway.
| | | | | |
Collapse
|
19
|
Abstract
BACKGROUND Croup is thought to be triggered by a viral infection and is characterised by respiratory distress due to upper airway inflammation and swelling of the subglottic mucosa in children. Mostly it is mild and transient and resolves with supportive care. In moderate to severe cases, treatment with corticosteroids and nebulised epinephrine (adrenaline) is required. Corticosteroids improve symptoms but it takes time for a full effect to be achieved. In the interim, the child is at risk of further deterioration. This may rarely result in respiratory failure necessitating emergency intubation and ventilation. Nebulised epinephrine may result in dose-related adverse effects including tachycardia, arrhythmias and hypertension and its benefit may be short-lived. Helium-oxygen (heliox) inhalation has shown therapeutic benefit in initial treatment of acute respiratory syncytial virus (RSV) bronchiolitis and may prevent morbidity and mortality in ventilated neonates. Heliox has been used during emergency transport of children with severe croup and anecdotal evidence suggests that heliox relieves respiratory distress. OBJECTIVES To examine the effect of heliox on relieving symptoms and signs of croup, as determined by a croup score (a tool for measuring the severity of croup).To examine the effect of croup on rates of admission or intubation (or both), through comparisons of heliox with placebo or any active intervention(s) in children with croup. SEARCH METHODS We searched CENTRAL 2013, Issue 10, MEDLINE (1950 to October week 5, 2013), EMBASE (1974 to November 2013), CINAHL (1982 to November 2013), Web of Science (1955 to November 2013) and LILACS (1982 to November 2013). In addition, we searched two clinical trials registries: the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and clinicaltrials.gov (searched 12 November 2013). SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing the effect of helium-oxygen mixtures with placebo or any active intervention(s) in children with croup. DATA COLLECTION AND ANALYSIS Two review authors independently identified and assessed citations for inclusion. A third review author resolved disagreements. We assessed included trials for allocation concealment, blinding of intervention, completeness of outcome data, selective outcome reporting and other potential sources of bias. We reported mean differences for continuous data and odds ratios for dichotomous data. We descriptively reported data not suitable for statistical analysis. MAIN RESULTS We included three RCTs with a total of 91 participants. One study compared heliox 70%/30% with 30% humidified oxygen administered for 20 minutes in children with mild croup and found no statistically significant differences in the overall change in croup scores between heliox and the comparator. In another study, children with moderate to severe croup were administered intramuscular dexamethasone 0.6 mg/kg and either heliox 70%/30% with one to two doses of nebulised saline, or 100% oxygen with one to two doses of nebulised racaemic epinephrine for three hours. In this study, the heliox group's croup scores improved significantly more at all time points from 90 minutes onwards. However, overall there were no significant differences in croup scores between the groups after four hours using repeated measures analysis. In a third study, children with moderate croup all received one dose of oral dexamethasone 0.3 mg/kg with heliox 70%/30% for 60 minutes in the intervention group and no treatment in the comparator. There was a statistically significant difference in croup scores at 60 minutes in favour of heliox but no significant difference after 120 minutes. It was not possible to pool outcomes because the included studies compared different interventions and reported different outcomes. No adverse events were reported. AUTHORS' CONCLUSIONS There is some evidence to suggest a short-term benefit of heliox inhalation in children with moderate to severe croup who have been administered oral or intramuscular dexamethasone. In one study, the benefit appeared to be similar to a combination of 100% oxygen with nebulised epinephrine. In another study there was a slight change in croup scores between heliox and controls, with unclear clinical significance. In another study in mild croup, the benefit of humidified heliox was equivalent to that of 30% humidified oxygen, suggesting that heliox is not indicated in this group of patients provided that 30% oxygen is available. Adequately powered RCTs comparing heliox with standard treatments are needed to further assess the role of heliox in children with moderate to severe croup.
Collapse
Affiliation(s)
- Irene Moraa
- School of Pharmacy, Pharmacy Australia Centre of Excellence, 20 Cornwall Street, Woolloongabba, Australia
| | | | | | | |
Collapse
|
20
|
Asthma essentials. Afr J Emerg Med 2013. [DOI: 10.1016/j.afjem.2012.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
21
|
Abstract
Pediatric asthma is a disease that is managed across outpatient physicians, hospitalists, critical care physicians, and emergency department (ED) physicians. Scoring systems may facilitate a rapid assessment of the child with asthma in the ED. Short-acting beta agonists are still the mainstay of therapy for acute exacerbations along with corticosteroids and ipratropium bromide. ED providers must also know the indications for noninvasive ventilation and intubation. Most patients can be treated and discharged from the ED after acute exacerbation, and should be given a plan for going home that provides educational material and emergency scenarios to help prevent future acute incidents.
Collapse
|