Managing an acute asthma exacerbation in children

Recommendations for Choosing Wisely in Pediatric Emergency Medicine: Five Opportunities to Improve Value

Unnecessary diagnostic tests and treatments in children cared for in emergency departments (EDs) do not benefit patients, increase costs, and may result in harm. To address this low-value care, a taskforce of pediatric emergency medicine (PEM) physicians was formed to create the first PEM Choosing Wisely recommendations. Using a systematic, iterative process, the taskforce collected suggested items from an interprofessional group of 33 ED clinicians from 6 academic pediatric EDs. An initial review of 219 suggested items yielded 72 unique items. Taskforce members independently scored each item for its extent of overuse, strength of evidence, and potential for harm. The 25 highest-rated items were sent in an electronic survey to all 89 members of the American Academy of Pediatrics PEM Committee on Quality Transformation (AAP COQT) to select their top ten recommendations. The AAP COQT survey had a 63% response rate. The five most selected items were circulated to over 100 stakeholder and specialty groups (within the AAP, CW Canada, and CW USA organizations) for review, iterative feedback, and approval. The final 5 items were simultaneously published by Choosing Wisely United States and Choosing Wisely Canada on December 1, 2022. All recommendations focused on decreasing diagnostic testing related to respiratory conditions, medical clearance for psychiatric conditions, seizures, constipation, and viral respiratory tract infections. A multinational PEM taskforce developed the first Choosing Wisely recommendation list for pediatric patients in the ED setting. Future activities will include dissemination efforts and interventions to improve the quality and value of care specific to recommendations.

A Review of the Latest Guidelines for Diagnosing and Managing Asthma in Children in the United States and Canada

Globally, asthma remains the most widespread chronic respiratory condition in children, with a larger proportion of children being affected by the condition. Regardless of the higher prevalence rates, the outcomes of pediatric asthma have remained inadequate, even as there are numerous preventable deaths (approximately 300 children in the United States and 250 children in Canada, annually). The characteristic symptoms of pediatric asthma include wheezing, cough, and shortness of breath that are characteristically triggered by several potential stimuli. However, several diagnostic challenges exist and have resulted in either overdiagnosis or underdiagnosis, making pediatric asthma diagnosis and management problematic. Effective management of asthma in children entails a holistic approach that encompasses non-pharmacological and pharmacological management, alongside self-management and educational aspects. Working with pediatric asthma patients and their families/caregivers is vital to promoting and realizing better asthma diagnosis and management outcomes. Educational guidelines regarding the best ways for effective treatment, avoidance of triggers, modifiable risk factors, and the actions that should be taken during chronic asthma attacks through individualized action plans are vital. Thus, the objective of this systematic review is to provide an overview of the latest guidelines on pediatric asthma diagnosis and management. In this regard, this review presents several similarities in existing pediatric asthma diagnosis and management guidelines in the United States and Canada. For instance, most guidelines and studies reviewed have proposed the use of objective tests for confirmation of asthma diagnosis, particularly in symptomatic individuals. The peak flow variability measurement, bronchodilator reversibility testing, and spirometry have also been proposed by the guidelines and studies, even as the recommendations regarding the timing and hierarchy of the objective test substantially vary between the guidelines and studies. We hope that the present review will be helpful to physicians and healthcare service providers working within pediatric health contexts.

Measuring evidence-based clinical guideline compliance in the paediatric intensive care unit

BACKGROUND

Evidence-based clinical care guidelines improve medical treatment by reducing error, improving outcomes and possibly lowering healthcare costs. While some data exist on individual guideline compliance, no data exist on overall compliance to multiple nuanced guidelines in a paediatric intensive care setting.

METHODS

Guideline compliance was observed and measured with a prospective cohort at a tertiary academic paediatric medical-surgical intensive care unit. Adherence to 19 evidence-based clinical care guidelines was evaluated in 814 patients, and reasons for non-compliance were noted along with other associated outcomes.

MEASUREMENTS AND MAIN RESULTS

Overall facility compliance was unexpectedly high at 77.8% over 4512 compliance events, involving 826 admissions. Compliance varied widely between guidelines. Guidelines with the highest compliance were stress ulcer prophylaxis (97.1%) and transfusion administration such as fresh frozen plasma (97.4%) and platelets (94.8%); guidelines with the lowest compliance were ventilator-associated pneumonia prevention (28.7%) and vitamin K administration (34.8%). There was no significant change in compliance over time with observation. Guidelines with binary decision branch points or single-page decision flow diagrams had a higher average compliance of 90.6%. Poor compliance was more often observed with poor perception of guideline trustworthiness and time limitations.

CONCLUSIONS

Measuring guideline compliance, though onerous, allowed for evaluation of current clinical practices and identified actionable areas for institutional improvement.

Implementing paediatric patient-reported outcome measures in outpatient asthma clinics: a feasibility assessment study

OBJECTIVE

Implementation of patient-reported outcome measures (PROMs) is limited in paediatric routine clinical care. The KidsPRO programme has been codesigned to facilitate the implementation of PROMs in paediatric healthcare settings. Therefore, this study (1) describes the development of innovative KidsPRO programme and (2) reports on the feasibility of implementing PedsQL (Pediatric Quality of Life Inventory) PROM in asthma clinics using the KidsPRO programme.

DESIGN

Feasibility assessment study.

SETTING

Outpatient paediatric asthma clinics in the city of Calgary, Canada.

PARTICIPANTS

Five paediatric patients, four family caregivers and three healthcare providers were recruited to pilot the implementation of PedsQL PROM using KidsPRO. Then, a survey was used to assess its feasibility among these study participants.

MAIN OUTCOME MEASURES

Participants' understanding of using PROMs, the adequacy of support provided to them, the utility of using PROMs as part of their appointment, and their satisfaction with using PROMs.

ANALYSES

The quantitative data generated through closed-ended questions was analysed and represented in the form of bar charts for each category of study participants (ie, patients, their family caregivers and healthcare providers). The qualitative data generated through the open-ended questions were content analysed and categorised into themes.

RESULTS

The experience of using PROMs was overwhelmingly positive among patients and their family caregivers, results were mixed among healthcare providers. Qualitative data collected through open-ended questions also complemented the quantitative findings.

CONCLUSION

The evidence from this study reveals that the implementation of PROMs in routine paediatric clinical care asthma clinics in Alberta is seems to be feasible.

Challenges in the Pharmacotherapeutic Management of Pediatric Asthma

Bronchial asthma is one of the most common chronic conditions in pediatric practice, with increasing prevalence hampered by poor socioeconomic impacts, leading to major public health issues. Considered as a complex heterogeneous syndrome, not a single disease, the management of the disease is a real challenge, impacting medical staff, patients and caregivers. Over the decades, a significant number of diagnostic and treatment regimen have been developed to achieve good standards, sustaining balanced control of the disease. This paper attempts a review on the establishment of new trends in the management of bronchial asthma in the pediatric age group.

Variation in low-value radiograph use for children in the emergency department: a cross-sectional study of administrative databases

BACKGROUND

Radiograph use contributes to low-value care for children in emergency departments (EDs), but little is known about systemic factors associated with their use. This study compares low-value radiograph use across ED settings by hospital type, pediatric volumes and physician specialty.

METHODS

This is a cross-sectional study of routinely collected administrative data. We included children (age 0-18 yr) discharged from EDs in Ontario, Canada, between 2010 and 2019 with diagnoses of bronchiolitis, asthma, abdominal pain and constipation. Multiple clinical practice guidelines recommend against routine radiograph use in these conditions. Logistic regression evaluated odds of low-value radiograph by ED setting (pediatric academic [referent], adult academic, community with or without pediatric consultation services), pediatric volume and physician specialty (pediatric emergency medicine [PEM, referent], emergency medicine [EM], family medicine with EM training, pediatrics, family medicine), adjusting for demographic, clinical and provider characteristics. We used generalized estimating equations to account for clustering by ED.

RESULTS

Of the total 9 862 787 eligible pediatric ED discharges in Ontario, 60 914 children had bronchiolitis, 141 921 asthma, 333 332 abdominal pain and 110 514 constipation; 26.0% received low-value radiographs. Compared with pediatric EDs and PEM physicians (referents), patients with bronchiolitis were most likely to have a chest radiograph in adult academic EDs (adjusted odds ratio [OR] 5.1 [95% confidence interval (CI) 4.6-5.6]) and by family physicians with EM training (adjusted OR 4.8 [95% CI 4.5-5.1]). Patients with asthma were more likely to have a chest radiograph in adult academic EDs (adjusted OR 3.0 [95% CI 2.8-3.2]) and by EM physicians (adjusted OR 2.8 [95% CI 2.6-3.0]). Patients with abdominal pain and constipation were more likely to have abdominal radiographs in community hospitals with pediatric consultation (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.3 [95% CI 2.3-2.4], respectively) and by family physicians with EM training (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.1 [95% CI 2.0-2.2], respectively).

INTERPRETATION

Over the decade-long study period, low-value radiograph use was frequent for children with 4 common conditions seen in Ontario EDs. Quality improvement initiatives aimed at reducing unnecessary radiographs in children should focus on EM physicians practising in EDs that primarily treat adult patients.

Stating the obvious: intravenous magnesium sulphate should be the first parenteral bronchodilator in paediatric asthma exacerbations unresponsive to first-line therapy

What is the most appropriate second-line intravenous bronchodilator treatment when a child with a severe asthma attack is not responsive to initial inhaled therapy? The second-line treatment options for acute asthma include parenteral β₂-agonists, methylxanthine and magnesium sulphate (MgSO₄). There is a poor evidence-base to inform this decision. This review argues that intravenous MgSO₄ is the obvious treatment of choice for this situation as the initial treatment based on current knowledge.  We describe the mode of action, scope and limitations of MgSO₄, safety profile, economic impact, comparisons of the alternatives, and finally, what the guidelines say.  This review explores the suitability of intravenous MgSO₄ as a pragmatic and safe initial second-line therapy for children unresponsive to initial asthma management.