Contemporary approach to the emergency department management of pediatric asthma

ADRB2 Gene Polymorphisms and Salbutamol Responsiveness in Serbian Children with Asthma

Inhaled β2 adrenergic receptor (β2-AR) agonists are the mainstay of asthma therapy. The β2-AR protein is encoded by the ADRB2 gene and variants within this gene can have significant consequences for modulating the response to asthma therapy. This cross-sectional study performed at the University Children’s Hospital in Belgrade, included 54 children with asthma. The subjects were genotyped for ADRB2 +46A>G (Arg16Gly, rs1042713) and +79C>G (Gln27Glu, rs 1042714) polymorphisms and the association with asthma severity and response to inhaled salbutamol was examined. In Serbian asthmatic children, allele +46A was detected with a frequency of 41.7% and allele +79G was detected with a frequency of 23.1%. Allele +46G was found to be associated with a better response to inhaled salbutamol (p <0.05) and with mild form of asthma (p <0.05). Polymorphism ADRB2 +46A>G may be a determinant of asthma severity and response to salbutamol in children with asthma. We did not find any association of +79C>G polymorphisms with the asthma severity and bronchodilator response to inhaled salbutamol. The results of this study can be potentially useful for personalization of asthma treatment.

Randomised comparison of intravenous magnesium sulphate, terbutaline and aminophylline for children with acute severe asthma

AIM

This study compared the efficacy of intravenous magnesium sulphate, terbutaline and aminophylline for children with acute, severe asthma poorly responsive to standard initial treatment.

METHODS

We enrolled 100 children, aged one to 12 years, who had failed to respond to initial standard treatment for acute, severe asthma, in this randomised controlled trial. They received either intravenous magnesium sulphate, terbutaline or aminophylline. Responses were monitored using a modified Clinical Asthma Severity (CAS) score. The primary outcome was treatment success, defined as a reduction in the CAS of four points or more 1 h after starting the intervention.

RESULTS

The magnesium sulphate group had higher treatment success (33/34, 97%) than the terbutaline and aminophylline groups (both 23/33, 70%) (p = 0.006) and faster resolution of retractions, wheeze and dyspnoea (p < 0.001). No adverse events occurred among patients receiving magnesium sulphate, but two patients receiving terbutaline had hypokalemia and nine patients receiving aminophylline had nausea and, or, vomiting.

CONCLUSION

Adding a single dose of Intravenous magnesium sulphate to inhaled beta2-agonists and corticosteroids was more effective, and safer, than using terbutaline or aminophylline when treating a child with acute severe asthma poorly responsive to initial treatment.

The Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED) improves physician assessment of asthma morbidity in pediatric emergency department patients

OBJECTIVES

To determine whether the Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED), a 12-item questionnaire, can help ED attendings accurately assess a patient's asthma control and morbidity.

METHODS

This was a randomized-controlled trial performed at an urban pediatric ED of children aged 1-17 years presenting with an asthma exacerbation. Parents answered PACCI-ED questions about their children's asthma. Attendings were randomized to view responses to the PACCI-ED (intervention group) or to be blinded to the completed PACCI-ED (control group). The two groups were compared on their empirical clinical assessment of: (1) chronic asthma control categories, (2) asthma trajectory (stable, worsening or improving), (3) patient adherence to controller medications, and (4) burden of disease for the patient's family. The validated PACCI algorithm was used as the criterion standard for these four outcomes. Accuracy of clinical assessment was compared between intervention and control groups using chi-squared tests and an intention-to-treat approach.

RESULTS

Seventeen ED attendings were enrolled in the study and 77 children visits were included in the analysis. There were no significant differences between the intervention and the control groups for child's gender, age, race, and asthma characteristics. Intervention group attendings were more accurate than control group attendings in assessing the category of chronic asthma control (43% versus 19%; p = 0.03), disease trajectory (72% versus 45%; p = 0.02), and the disease burden for families (74% versus 35%; p = 0.001) over the past 12 months. There was a trend towards more accuracy of intervention versus control attendings for estimating patient adherence to controller medications (72% versus 48%; p = 0.06).

CONCLUSIONS

The PACCI-ED improves the assessment of asthma control, trajectory, and burden by ED attendings, and may help assessment of asthma medication adherence and prior asthma exacerbations. The PACCI-ED can be used to improve provider assessment of asthma morbidity during pediatric ED visits for asthma exacerbations, and to identify children who may benefit from interventions to reduce asthma morbidity.

Childhood asthma: a guide for pediatric emergency medicine providers

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.

Compliance with guidelines for emergency management of asthma in adults: experience at a tertiary care teaching hospital

OBJECTIVES

Despite evidence-based clinical practice guidelines for the emergency management of asthma, substantial treatment variation exists. Our objective was to assess compliance with the Canadian Association of Emergency Physicians (CAEP) / Canadian Thoracic Society (CTS) Asthma Advisory Committee's "Guidelines for the emergency management of asthma in adults" in the emergency department (ED) of a university-affiliated tertiary care teaching hospital.

METHODS

This retrospective study was conducted in a Canadian inner city adult ED. Investigators reviewed all ED records for the period from Jan. 1, 2001, to Dec. 31, 2001, and identified adult patients (i.e., >18 years of age) with a primary ED diagnosis of asthma. Hospital records were then reviewed to document compliance with the CAEP/CTS asthma guidelines. Descriptive statistics, including means, standard deviations and frequencies were used to summarize information.

RESULTS

Overall compliance with the guidelines was 69.6%, (95% confidence interval, 64.7%-74.5%), but compliance ranged from 41.4% for severe asthma, 67.1% for moderate asthma, and 88.6% for mild asthma. Interobserver reliability for compliance assessment was excellent.

CONCLUSIONS

Despite publication and dissemination of evidence-based guidelines for the management of acute asthma in adults, guideline compliance at a university-affiliated, inner city, tertiary care teaching hospital ED is suboptimal.

Beta2-adrenergic receptor polymorphisms affect response to treatment in children with severe asthma exacerbations

BACKGROUND

beta(2)-adrenergic receptor (AR) agonists are the mainstay of treatment for severe asthma exacerbations, one of the most common causes of critical illness in children. Genotypic differences in the beta(2)-AR gene, particularly at amino acid positions 16 and 27, have been shown to affect the response to beta(2)-AR agonist therapy. Our hypothesis is that genotypic differences contribute to patient response to beta(2)-AR agonist treatment during severe asthma exacerbations in children.

METHODS

Children admitted to the hospital ICU for a severe asthma exacerbation between 2002 and 2005 were located, and genetic samples were obtained from saliva. Children hospitalized during this period were treated with a protocol that titrated beta(2)-AR therapy (first nebulized, then IV) according to a validated clinical asthma score.

RESULTS

Thirty-seven children hospitalized during the study period were enrolled into the study. At amino acid position 16 in the beta(2)-AR gene, 13 children were homozygous for the glycine (Gly) allele (Gly/Gly), 8 were homozygous for the arginine (Arg) allele (Arg/Arg), and 16 were heterozygous (Arg/Gly). Despite similar clinical asthma scores on hospital admission, the children with the Gly/Gly genotype had significantly shorter hospital ICU length of stay and duration of continuously nebulized albuterol therapy and were significantly less likely to require IV beta(2)-AR therapy than those with Arg/Arg or Arg/Gly genotypes. No association existed among polymorphisms at amino acid position 27 and response to beta(2)-AR therapy.

CONCLUSIONS

In this cohort of children with severe asthma exacerbations, children whose genotypes were homozygous for Gly at amino acid position 16 of the beta(2)-AR gene had a more rapid response to beta(2)-AR agonist treatment. The beta(2)-AR genotype appears to influence the response to therapy in this population.

Slow-responders to IV beta2-adrenergic agonist therapy: defining a novel phenotype in pediatric asthma

OBJECTIVES

While aerosolized administration of beta(2)-adrenergic receptor (beta(2)-AR) agonists is the mainstay of treatment for pediatric asthma exacerbations, the efficacy of intravenous (IV) delivery is controversial. Failure to demonstrate improved outcomes with IV beta(2)-AR agonists may be due to phenotypic differences within this patient population. Our hypothesis is that children who respond more slowly to IV beta(2)-AR agonist therapy comprise a distinct phenotype.

METHODS

Retrospective chart review of all children admitted to the ICU for status asthmaticus who were treated with IV terbutaline between December 2002 and September 2006.

RESULTS

Seventy-eight children were treated with IV terbutaline according to guidelines that adjusted the dose by clinical asthma score. After examining the histogram of duration of terbutaline infusions, a 48-hr cutoff was chosen to define responsiveness. Thirty-eight (49%) children were slow-responders by this definition. There were no significant differences in baseline asthma severity or severity on admission between the slow-responders and responders. Slow-responders required significantly higher total doses of IV terbutaline, higher maximum administration rates, and had longer ICU and hospital length of stay.

CONCLUSION

There were significant differences in outcomes between the responders and slow-responders without differences in acute or chronic illness severity. Other factors may have lead to slower response to IV beta(2)-agonist therapy.

Initiation of maintenance antiinflammatory medication in asthmatic children in a pediatric emergency department

BACKGROUND

Despite National Asthma Education and Prevention Program guidelines recommending the use of daily controller medication in patients with persistent asthma, less than half of children requiring emergency department treatment for asthma exacerbations are receiving antiinflammatory therapy.

OBJECTIVE

The purpose of this study was to evaluate a pediatric emergency department-based intervention designed to affect the prescribing practices of primary care physicians to better comply with national asthma guidelines. The intervention involved initiating maintenance antiinflammatory therapy in children with an asthma exacerbation who met guidelines for persistent disease but were not on antiinflammatory medications.

METHODS

Guardians of children 2 to 18 years of age presenting to the pediatric emergency department with an asthma exacerbation were asked to complete an asthma survey. Patients were classified into severity categories. Those with persistent disease not on antiinflammatory medications were given a 2-week supply of medication and were instructed to follow-up with their primary care physicians to obtain a prescription for the antiinflammatory medication. Patient adherence information was obtained through telephone calls, pharmacy claims data, and physician office records.

RESULTS

Forty-seven of 142 patients met criteria and were enrolled in the intervention. Seven patients were lost to follow-up. Of the remaining 40 patients, 28 followed-up with their primary care physician. Of these patients, 75% were continued on an antiinflammatory medication. Primary care physicians were significantly more likely to continue an antiinflammatory prescription in patients with severe persistent asthma (88.9% vs 68.4% of mild- or moderate-persistent asthmatics). Of the 28 patients who followed-up with their primary care physician, 13 had a prescription written, dispensed, and reported using the medication at the time of follow-up.

CONCLUSIONS

Pediatric emergency department physicians can successfully partner with primary care physicians to implement national guidelines for children requiring maintenance antiinflammatory asthma therapy. Patient nonadherence continues to be a significant barrier for asthma management.

Prehospital asthma management

The treatment of acute asthma exacerbation consumes a significant portion of emergency medical services (EMS) system resources. Because few studies have addressed EMS treatment of asthma, most EMS providers model their approach to treatment on strategies thought to be effective in the emergency department. During the treatment of asthma, a patient's history and current airway and respiratory status are important components of the initial assessment. Although the general evaluation may address a patient's appearance, vital signs, mental status, level of fatigue, and ability to speak normally, the initial assessment of an asthmatic patient must focus specifically on his or her respiratory effort and quality and on objective measurement of the patient's blood oxygenation. Inhaled beta-agonist therapy is the widely recommended first choice of treatment, but anticholinergic agents and steroids may also have roles. Although not routine treatments, parenteral magnesium and epinephrine may also be beneficial for certain patients. Endotracheal intubation is a procedure of last resort and should be reserved for patients at immediate risk of respiratory arrest. Finally, EMS providers must be alert to the danger of using a "treat and release" approach, as recommended by some protocols, in the treatment of acute asthma. The quick results and benefit that short-acting treatments provide can easily and erroneously lead a provider to believe that an attack has been adequately controlled when, in fact, a more serious exacerbation may be imminent. Treatment protocols, therefore, should discourage EMS personnel from this practice and advise them to always transport asthmatic patients they have treated to the hospital to undergo more extended care and monitoring.