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Lee B, Turner S, Borland M, Csonka P, Grigg J, Guilbert TW, Jartti T, Oommen A, Twynam-Perkins J, Lewis S, Cunningham S. Efficacy of oral corticosteroids for acute preschool wheeze: a systematic review and individual participant data meta-analysis of randomised clinical trials. THE LANCET. RESPIRATORY MEDICINE 2024; 12:444-456. [PMID: 38527486 DOI: 10.1016/s2213-2600(24)00041-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Oral corticosteroids are commonly used for acute preschool wheeze, although there is conflicting evidence of their benefit. We assessed the clinical efficacy of oral corticosteroids by means of a systematic review and individual participant data (IPD) meta-analysis. METHODS In this systematic review with IPD meta-analysis, we systematically searched eight databases (PubMed, Ovid Embase, CINAHLplus, CENTRAL, ClinicalTrials.gov, EudraCT, EU Clinical Trials Register, WHO Clinical Trials Registry) for randomised clinical trials published from Jan 1, 1994, to June 30, 2020, comparing oral corticosteroids with placebo in children aged 12 to 71 months with acute preschool wheeze in any setting based on the Population, Intervention, Comparison, Outcomes framework. We contacted principal investigators of eligible studies to obtain deidentified individual patient data. The primary outcome was change in wheezing severity score (WSS). A key secondary outcome length of hospital stay. We also calculated a pooled estimate of six commonly reported adverse events in the follow-up period of IPD datasets. One-stage and two-stage meta-analyses employing a random-effects model were used. This study is registered with PROSPERO, CRD42020193958. FINDINGS We identified 16 102 studies published between Jan 1, 1994, and June 30, 2020, from which there were 12 eligible trials after deduplication and screening. We obtained individual data from seven trials comprising 2172 children, with 1728 children in the eligible IPD age range; 853 (49·4%) received oral corticosteroids (544 [63·8%] male and 309 [36·2%] female) and 875 (50·6%) received placebo (583 [66·6%] male and 292 [33·4%] female). Compared with placebo, a greater change in WSS at 4 h was seen in the oral corticosteroids group (mean difference -0·31 [95% CI -0·38 to -0·24]; p=0·011) but not 12 h (-0·02 [-0·17 to 0·14]; p=0·68), with low heterogeneity between studies (I2=0%; τ2<0·001). Length of hospital stay was significantly reduced in the oral corticosteroids group (-3·18 h [-4·43 to -1·93]; p=0·0021; I2=0%; τ2<0·001). Subgroup analyses showed that this reduction was greatest in those with a history of wheezing or asthma (-4·54 h [-5·57 to -3·52]; pinteraction=0·0007). Adverse events were infrequently reported (four of seven datasets), but oral corticosteroids were associated with an increased risk of vomiting (odds ratio 2·27 [95% CI 0·87 to 5·88]; τ2<0·001). Most datasets (six of seven) had a low risk of bias. INTERPRETATION Oral corticosteroids reduce WSS at 4 h and length of hospital stay in children with acute preschool wheeze. In those with a history of previous wheeze or asthma, oral corticosteroids provide a potentially clinically relevant effect on length of hospital stay. FUNDING Asthma UK Centre for Applied Research.
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Affiliation(s)
- Bohee Lee
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK.
| | - Steve Turner
- Royal Aberdeen Children's Hospital, NHS Grampian, Aberdeen, UK
| | - Meredith Borland
- Perth Children's Hospital Emergency Department and Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, WA, Australia
| | - Péter Csonka
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Terveystalo Healthcare, Tampere, Finland
| | - Jonathan Grigg
- Centre for Genomics and Child Health, Queen Mary University of London, London, UK
| | - Theresa W Guilbert
- Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Tuomas Jartti
- Department of Pediatrics, Turku University Hospital and University of Turku, Turku, Finland; PEDEGO Research Unit, University of Oulu, Oulu, Finland; Department of Pediatrics, Oulu University Hospital, Oulu, Finland
| | - Abraham Oommen
- Department of Paediatrics, Milton Keynes University Hospital NHS Trust, Milton Keynes, UK
| | - Jonathan Twynam-Perkins
- Department of Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK; Department of Paediatric Respiratory and Sleep Medicine, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Steff Lewis
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK; Usher Institute, and Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Steve Cunningham
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK; Department of Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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Pierantoni L, Andreozzi L, Stera G, Toschi Vespasiani G, Biagi C, Zama D, Balduini E, Scheier LM, Lanari M. National survey conducted among Italian pediatricians examining the therapeutic management of croup. Respir Med 2024; 226:107587. [PMID: 38522591 DOI: 10.1016/j.rmed.2024.107587] [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: 03/29/2023] [Revised: 02/10/2024] [Accepted: 03/05/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVES Practice-to-recommendations gaps exist in croup management and have not been critically investigated. This study examined the therapeutic management of croup among a national sample of Italian pediatric providers. METHODS A survey was administered online to a sample of primary care and hospital-based pediatricians. Demographic data, perception regarding disease severity, treatment and knowledge of croup, choices of croup treatment medications, and knowledge of and adherence to treatment recommendations were compared between hospital and primary care pediatricians. Oral corticosteroids alone, oral corticosteroids with or without nebulized epinephrine and nebulized epinephrine plus oral or inhaled corticosteroids were considered the correct management in mild, moderate and severe croup, respectively. The determinants for correct management were examined using multivariate logistic regression analysis. RESULTS Six hundred forty-nine pediatricians answered at least 50% of the survey questions and were included in the analysis. Providers reported extensive use of inhaled corticosteroids for mild and moderate croup. Recommended treatment for mild, moderate and severe croup was administered in 46/647 (7.1%), 181/645 (28.0%) and 263/643 (40.9%) participants, respectively. Provider's age and knowledge of Westley Croup Score were significant predictors for correct management of mild croup. Being a hospital pediatrician and perception of croup as a clinically relevant condition were significant for moderate croup. CONCLUSIONS Significant differences exist between recommended guidelines and clinical practice in croup management. This study suggests wide variability in both the treatment of croup and clinical decision making strategies among hospital and primary care pediatricians. Addressing this issue could lead to noteworthy clinical and economic benefits.
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Affiliation(s)
- Luca Pierantoni
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Laura Andreozzi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
| | - Giacomo Stera
- Specialty School of Paediatrics, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | - Gaia Toschi Vespasiani
- Specialty School of Paediatrics, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | - Carlotta Biagi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Daniele Zama
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Elena Balduini
- Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | | | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Rojas-Anaya H, Kapur A, Roberts G, Roland D, Gupta A, Lazner M, Bayreuther J, Pappachan J, Jones C, Bremner S, Cantle F, Seddon P. High-Flow Humidified Oxygen as an Early Intervention in Children With Acute Severe Asthma: Protocol for a Feasibility Randomized Controlled Trial. JMIR Res Protoc 2024; 13:e54081. [PMID: 38546733 PMCID: PMC11009849 DOI: 10.2196/54081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/25/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Acute severe asthma (ASA) is a leading cause of hospital attendance in children. Standard first-line therapy consists of high-dose inhaled bronchodilators plus oral corticosteroids. Treatment for children who fail to respond to first-line therapy is problematic: the use of intravenous agents is inconsistent, and side effects are frequent. High-flow humidified oxygen (HiFlo) is widely used in respiratory conditions and is increasingly being used in ASA, but with little evidence for its effectiveness. A well-designed, adequately powered randomized controlled trial (RCT) of HiFlo therapy in ASA is urgently needed, and feasibility data are required to plan such an RCT. In this study, we describe the protocol for a feasibility study designed to fill this knowledge gap. OBJECTIVE This study aims to establish whether a full RCT of early HiFlo therapy in children with ASA can be conducted successfully and safely, to establish whether recruitment using deferred consent is practicable, and to define appropriate outcome measures and sample sizes for a definitive RCT. The underlying hypothesis is that early HiFlo therapy in ASA will reduce the need for more invasive treatments, allow faster recovery and discharge from hospital, and in both these ways reduce distress to children and their families. METHODS We conducted a feasibility RCT with deferred consent to assess the use of early HiFlo therapy in children aged 2 to 11 years with acute severe wheeze not responding to burst therapy (ie, high-dose inhaled salbutamol with or without ipratropium). Children with a Preschool Respiratory Assessment Measure score ≥5 after burst therapy were randomized to commence HiFlo therapy or follow standard care. The candidate primary outcomes assessed were treatment failure requiring escalation and time to meet hospital discharge criteria. Patient and parent experiences were also assessed using questionnaires and telephone interviews. RESULTS The trial was opened to recruitment in February 2020 but was paused for 15 months owing to the COVID-19 pandemic. The trial was reopened at the lead site in July 2021 and opened at the other 3 sites from August to December 2022. Recruitment was completed in June 2023. CONCLUSIONS This feasibility RCT of early HiFlo therapy in children with ASA recruited to the target despite major disturbances owing to the COVID-19 pandemic. The data are currently being analyzed and will be published separately. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number Registry ISRCTN78297040; https://www.isrctn.com/ISRCTN78297040. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/54081.
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Affiliation(s)
- Hector Rojas-Anaya
- University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
- Brighton and Sussex Clinical Trials Unit, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Akshat Kapur
- Respiratory Care, Royal Alexandra Children's Hospital, University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
| | - Graham Roberts
- Department of Paediatric Allergy and Respiratory Medicine, University of Southampton, Southampton, United Kingdom
- National Institute for Heath Research Southampton Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, United Kingdom
- Social science APPlied Healthcare and Improvement REsearch Group, Department of Population Health Sciences, Leicester University, Leicester, United Kingdom
| | - Atul Gupta
- Paediatric Respiratory Medicine, King's College Hospital, London, United Kingdom
| | - Michaela Lazner
- Children's Emergency Department, Royal Alexandra Children's Hospital, University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
| | - Jane Bayreuther
- Children's Emergency Department, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - John Pappachan
- National Institute for Heath Research Southampton Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Christina Jones
- School of Psychology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Stephen Bremner
- Brighton and Sussex Clinical Trials Unit, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Fleur Cantle
- Emergency Department, King's College Hospital, London, United Kingdom
| | - Paul Seddon
- Respiratory Care, Royal Alexandra Children's Hospital, University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
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Al-Moamary MS, Alhaider SA, Allehebi R, Idrees MM, Zeitouni MO, Al Ghobain MO, Alanazi AF, Al-Harbi AS, Yousef AA, Alorainy HS, Al-Hajjaj MS. The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2024; 19:1-55. [PMID: 38444991 PMCID: PMC10911239 DOI: 10.4103/atm.atm_248_23] [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: 10/01/2023] [Accepted: 10/31/2023] [Indexed: 03/07/2024] Open
Abstract
The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.
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Affiliation(s)
- Mohamed Saad Al-Moamary
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A. Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Riyad Allehebi
- Department of Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Majdy M. Idrees
- Department of Medicine, Respiratory Division, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed O. Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohammed O. Al Ghobain
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdullah F. Alanazi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Adel S. Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hassan S. Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohamed S. Al-Hajjaj
- Department of Paediatrics, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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Johnson MD, Barney BJ, Rower JE, Finkelstein Y, Zorc JJ. Intravenous Magnesium: Prompt Use for Asthma in Children Treated in the Emergency Department (IMPACT-ED): Protocol for a Multicenter Pilot Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e48302. [PMID: 37459153 PMCID: PMC10391520 DOI: 10.2196/48302] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/26/2023] [Accepted: 05/29/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Children managed for asthma in an emergency department (ED) may be less likely to be hospitalized if they receive intravenous magnesium sulfate (IVMg). Asthma guidelines recommend IVMg for severely sick children but note a lack of evidence to support this recommendation. All previous trials of IVMg in children with asthma have been too small to answer whether IVMg is effective and safe. A few major questions remain about IVMg. First, it has not been tested early in the course of ED treatment, when the impact on hospitalization would be greatest. Second, the clinical impact of hypotension, a known adverse effect of IVMg, has not been well characterized in previous research. Third, no trials have compared different IVMg doses or serial serum magnesium (total and ionized) concentrations to optimize dosing, so the most effective dose is unknown. A large, conclusive, randomized, placebo-controlled clinical trial of IVMg might be challenging due to the need to enroll and complete study procedures quickly, a lack of understanding of blood pressure changes after IVMg, and a lack of pharmacologic information to guide the optimal doses of IVMg to be tested. Therefore, a pilot study to inform the above gaps is warranted before conducting a definitive trial. OBJECTIVE The objectives of this study are to (1) demonstrate the feasibility of enrolling children with severe acute asthma in the ED in a multicenter, randomized controlled trial of a placebo, low-dose IVMg, or high-dose IVMg; (2) demonstrate the feasibility of timely delivery of study medication, assessment of blood pressure, and evaluation of adverse events in a standardized protocol; and (3) externally validate a previously constructed pharmacokinetic model and develop a combined pharmacokinetic/pharmacodynamic model for IVMg using magnesium (total and ionized) serum concentrations and their correlation with measures of efficacy and safety. METHODS This pilot trial tests procedures and gathers information to plan a definitive trial. The pilot trial will enroll as many as 90 children across 3 sites, randomize each child to 1 of 3 study arms, measure blood pressure frequently, and collect 3 blood samples from each participant with corresponding clinical asthma scores. RESULTS The project was funded by the National Heart, Lung, and Blood Institute (1 R34HL152047-2) in March 2022. Enrollment began in September 2022, and 43 children have been enrolled as of April 2023. We will submit the results for publication in late 2023. CONCLUSIONS The results of this study will guide the planning of a large, definitive, multicenter trial powered to evaluate if IVMg reduces hospitalization. Blood pressure measurements will inform a monitoring plan for the larger trial, and blood samples and asthma scores will be used to validate pharmacologic models to select the optimal dose of IVMg to be evaluated in the definitive trial. TRIAL REGISTRATION ClinicalTrials.gov NCT05166811; https://clinicaltrials.gov/ct2/show/NCT05166811. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/48302.
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Affiliation(s)
- Michael D Johnson
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Bradley J Barney
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Joseph E Rower
- Department of Pharmacology and Toxicology, University of Utah College of Pharmacy, Salt Lake City, UT, United States
| | - Yaron Finkelstein
- Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Joseph J Zorc
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
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Almazroea AH, Alharbi AH, Alawfi BA, Alsaedi BQ, Samman RS, Almohalwas MA. Does Good Nebulization Therapy in the Emergency Room Reduce the Need for Hospitalization in Asthmatic Children? Cureus 2023; 15:e41270. [PMID: 37533610 PMCID: PMC10391584 DOI: 10.7759/cureus.41270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2023] [Indexed: 08/04/2023] Open
Abstract
INTRODUCTION Asthma is a chronic inflammatory disorder characterized by obstruction, hyperresponsiveness, and inflammatory changes in the airways. The overall prevalence of asthma in Saudi Arabian children ranges from 8% to 25%. Studies have shown that children who did not respond adequately to treatment in the emergency room (ER) were admitted to hospital for additional treatment which increased the cost and risk of hospital-acquired infections. The quality of nebulization therapy is influenced by several factors such as the position, dose, oxygen flow rate, and duration of treatment. Objectives: In this study, we aimed to explore factors that affect nebulization therapy in ER and to assess the relation between nebulization technique in ER and hospital admission for asthmatic children, and these aims were achieved over the period from December 2021 to May 2023. METHODOLOGY An observational cross-sectional study was conducted in Maternity and Children Hospital (MCH) in Medina at the ER over the period from December 2021 to May 2023 for all children admitted to ER with asthma exacerbation. The sample size used to include patients in the study is 289 calculated using the Openepi website. Data were collected by observation and using medical records of the patients and analyzed using Statistical Package for Social Sciences (SPSS) version 26.0 (IBM Corp., Armonk, NY, USA). RESULTS The total number of the sample was 289 children ages between two to 14 years. Sixty-four percent (n=185) reported as their gender as male while 36% (n = 104) as female. The median age of the children was four years old (interquartile range [IQR] = 4), and their median weight was 15 kg (IQR = 8.15). Also, more than 83% of the patients has mild asthma, while 16.3% of the sample were diagnosed with moderate to severe asthma. Besides, 92.4% of the sample was discharged from a hospital, and 76.5% received an appropriate dose of nebulization. DISCUSSION After reviewing the results of the statistical analysis, the main findings were that the severity of asthma exacerbation was the most important factor influencing the outcome. It was found that 0.4% of patients with mild asthma were admitted to the hospital, compared to 44.7% of patients with moderate to severe asthma. CONCLUSION Our study assessed whether effective nebulization therapy in the ER will reduce the need for hospitalization in asthmatic children and the results indicate that the severity of asthma exacerbation was the most significant factor impacting hospital admission in asthmatic patients and influenced other factors of nebulization therapy. However, the other factors, such as the patient position, oxygen flow rate, and the dose of medications did not show any clinically significant impact on hospitalization rates.
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Affiliation(s)
| | - Ahmad H Alharbi
- Pediatric Emergency Medicine, Maternity and Children Hospital in Madinah, Al-Madinah Al-Munawwarah, SAU
| | - Bushra A Alawfi
- Pediatrics, Taibah University, Al-Madinah Al-Munawwarah, SAU
| | | | - Razan S Samman
- Pediatrics, Taibah University, Al-Madinah Al-Munawwarah, SAU
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Freedman MS, Forno E. Initial emergency department vital signs may predict PICU admission in pediatric patients presenting with asthma exacerbation. J Asthma 2023; 60:960-968. [PMID: 35943201 PMCID: PMC10027615 DOI: 10.1080/02770903.2022.2111686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 07/29/2022] [Accepted: 08/07/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE Severe asthma exacerbations account for a large share of asthma morbidity, mortality, and costs. Here, we aim to identify early predictive factors associated with pediatric intensive care unit (PICU) admission. METHODS We performed a retrospective observational study of 5,185 emergency department (ED) encounters at a large children's hospital, including 86 (1.7%) resulting in PICU admission between 10/1/2015 and 8/7/2018 with ICD9/ICD10 codes for "asthma," "bronchospasm," or "wheezing." Vital signs and demographic information were obtained from electronic health record data and analyzed for each encounter. Predictive factors were identified using adjusted regression models, and our primary outcome was PICU admission. RESULTS Higher mean heart rates (HRs) and respiratory rates (RRs), and lower SpO2 within the first hour of ED presentation were independently associated with PICU admission. Odds of PICU admission increased 70% for each 10 beats/min higher HR, 125% for each 10 breaths/min higher RR, and 34% for each 5% lower SpO2. A binary predictive index using 1-h vitals yielded OR 13.4 (95% CI 8.1-22.1) for PICU admission, area under receiver operator characteristic (AUROC) curve 0.84 and overall accuracy of 80.1%. Results were largely unchanged (AUROC 0.84-0.88) after adjusting for surrogates of asthma severity and initial ED management. In combination with a secondary standardized clinical asthma distress score, positive predictive value increased by sevenfold (6.1%-46%). CONCLUSIONS A predictive index using HR, RR, and SpO2 within the first hour of ED presentation accurately predicted PICU admission in this cohort. Automated vital signs trend analysis may help identify vulnerable patients quickly upon presentation.
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Affiliation(s)
- Michael S Freedman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Lucile Packard Children’s Hospital
- Department of Biomedical Data Science, Stanford University School of Medicine, Palo Alto, CA
| | - Erick Forno
- Division of Pulmonary Medicine, Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Granda E, Urbano M, Andrés P, Corchete M, Cano A, Velasco R. Comparison of severity scales for acute bronchiolitis in real clinical practice. Eur J Pediatr 2023; 182:1619-1626. [PMID: 36702906 DOI: 10.1007/s00431-023-04840-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 01/09/2023] [Accepted: 01/21/2023] [Indexed: 01/28/2023]
Abstract
Several clinical scales have been developed to assess the severity of bronchiolitis as well as the probability of needing in-hospital care. A recent systematic review of 32 validated clinical scores for bronchiolitis concluded that 6 of them (Wood-Downes, M-WCAS, Respiratory Severity Score, Respiratory Clinical Score, Respiratory Score and Bronchiolitis risk of admission score) were the best ones regarding reliability, sensitivity, validity, and usability. However, to the best of our knowledge, no study has compared all of them in a clinical scenario. Also, after this review, three more scales were published: BROSJOD, Tal modified, and one score developed by PERN. Our main aim was to compare the ability of different clinical scales for bronchiolitis to predict any relevant outcome. A prospective observational study was conducted that included patients of up to 12 months old attended to, due to bronchiolitis, in the paediatric Emergency Department of a secondary university hospital from October 2019 to January 2022. For each patient, the attending clinician filled in a form with the items of the scales, decomposed, in order to prevent the clinician from knowing the score of each scale. Then, the patient was managed according to the protocol of our Emergency Department. A phone call was made to each patient in order to check whether the patient ended up being admitted in the next 48 h. In the case of those that were impossible to contact by phone, the clinical history was reviewed. For the purpose of the study, any of the following were considered to be a relevant outcome: admission to ward and need for supplementary oxygen, non-invasive ventilation (NIV) or intravenous fluids, and admission to the paediatric intensive care unit (PICU) within the next 48 h or death. For the aim of the study, the area under the curve (AUC) and the odds ratio (OR) for a relevant outcome were calculated in each scale. Also, the best cut-off point was estimated according to the Youden index, and its sensitivity (Sn) and specificity (Sp) for a relevant outcome were calculated. We included 265 patients (52.1% male) with a median age of 5.3 months (P25-P75 2.6-7.4). Among them, 46 (17.4%) had some kind of relevant outcome. AUC for prediction of a relevant outcome ranged from 0.705 (Respiratory Score) to 0.786 (BRAS), although no scale performed significantly better than others. A score ≤ 2 in the PERN scale showed a sensitivity of 91.3% (CI95% 79.7-96.6) for a relevant outcome, with only 4 misdiagnosed patients (only 2 of them needed NIV). Conclusions: There were no differences in the performance of the nine scales to predict relevant outcomes in patients with bronchiolitis. However, the PERN scale might be more useful to select patients at low risk of a severe outcome. What is Known: • Several clinical scales are used to assess the severity of bronchiolitis. Nevertheless, none of them seems to be better than others. What is New: • This is the first study comparing different bronchiolitis scales in a real clinical scenario. None of the nine scales compared performed better than the other. However, the PERN scale might be more useful to select patients at low risk of relevant outcomes.
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Affiliation(s)
- Elena Granda
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain.
| | - Mario Urbano
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Pilar Andrés
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Marina Corchete
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Alfredo Cano
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Roberto Velasco
- Pediatric Emergency Department, Hospital Universitario Río Hortega, Valladolid, Spain
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9
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Assessment and management of asthma exacerbations in an emergency department unit. Allergol Immunopathol (Madr) 2023; 51:74-76. [PMID: 36617824 DOI: 10.15586/aei.v51i1.720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/21/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND The Pediatric Respiratory Assessment Measure (PRAM) score is a useful tool for the assessment of asthma exacerbations in children. This study aimed to estimate the risk of hospitalization in children, assessed with the PRAM score and having mild-moderate asthma exacerbation, who were treated with salbutamol delivered via a metered-dose inhaler and spacer (MDI/S). METHODS The study population consisted of children aged 3-16 years with mild-moderate asthma exacerbations. All children received 1mg/kg prednisolone p.o. (max 40 mg) and 4-6 puffs of salbutamol via MDI/S. RESULTS Fifty patients participated in the study. Admission was associated positively with the initial PRAM score (OR: 18.91, CI: 2.42-123.12, P = 0.005) and negatively with the improvement in PRAM score (OR: 0.52, CI: 0.01-0.78, P = 0.032). CONCLUSION PRAM is a reliable tool that can be used effectively to estimate the asthma exacerbation severity.
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10
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Kosoko AA, Khoei AA, Khose S, Genisca AE, Mackey JM. Evaluating the Clinical Impact of a Novel Pediatric Emergency Medicine Curriculum on Asthma Outcomes in Belize. Pediatr Emerg Care 2022; 38:598-604. [PMID: 36314861 PMCID: PMC9640288 DOI: 10.1097/pec.0000000000002850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Respiratory-related complaints prompt most pediatric visits to Karl Heusner Memorial Hospital Authority's (KHMHA) Emergency Department (ED) in Belize. We developed and taught a novel pediatric respiratory emergencies module for generalist practitioners there. We assessed the curriculum's clinical impact on pediatric asthma emergency management. OBJECTIVE This study assesses the clinical impact of a pediatric emergency medicine curriculum on management of pediatric asthma emergencies at KHMHA in Belize City, Belize. METHODS We conducted a randomized chart review of pediatric (aged 2-16 y) visits for asthma-related diagnosis at the KHMHA ED between 2015 and 2018 to assess the training module's clinical impact. Primary outcomes included time to albuterol and steroids. Secondary outcomes included clinical scoring tool (Pediatric Respiratory Assessment Measure [PRAM]) usage, ED length of stay, usage of chest radiography, return visit within 7 days, and hospital admission rates. Kaplan-Meier survival analysis and Cox proportional hazard regression were used. RESULTS Two hundred eighty-three pediatric asthma-related diagnoses met our inclusion criteria. The patients treated by trained and untrained physician groups were demographically and clinically similar. The time to albuterol was significantly faster in the trained (intervention) group compared with the untrained (control) physician group when evaluating baseline of the group posttraining (P < 0.05). However, the time to steroids did not reach statistical significance posttraining (P = 0.93). The PRAM score utilization significantly increased among both control group and intervention group. The untrained physician group was more likely to use chest radiography or admit patients. The trained physician group had higher return visit rates within 7 days and shorter ED length of stay, but this did not reach statistical significance. CONCLUSIONS The curriculum positively impacted clinical outcomes leading to earlier albuterol administration, increased PRAM score use, obtaining less chest radiographs, and decreased admission rates. The timeliness of systemic steroid administration was unaffected.
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Affiliation(s)
- Adeola A. Kosoko
- From the Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | | | - Swapnil Khose
- From the Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Alicia E. Genisca
- Departments of Emergency Medicine and Pediatrics, The Warren Alpert Medical School of Medicine, Brown University/Hasbro Children's Hospital, Providence, RI
| | - Joy M. Mackey
- Henry J.N. Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
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11
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McBride SC, McCarty K, Wong J, Baskin M, Currier D, Chiang VW. A pediatric hospital-wide asthma severity score: Reliability and effectiveness. Pediatr Pulmonol 2022; 57:1223-1228. [PMID: 35182050 DOI: 10.1002/ppul.25861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 01/14/2022] [Accepted: 02/12/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Asthma is a leading cause of pediatric hospitalization in the United States. Children hospitalized with asthma are often managed in different care settings during hospitalization, posing challenges to accurate communication among care providers about illness severity. Our objective was to study the feasibility, reliability, and safety of a new pediatric hospital-wide asthma severity score (HASS) across different care units within a single tertiary-care pediatric center. METHODS 150 patients between the ages of 2 and 18 years hospitalized with a principal diagnosis of status asthmaticus were included in this study. Study patients were followed from the time of initial triage in the emergency department until the time of medical readiness for discharge. Rates of medical errors, early transfers to a higher level of care and medically indicated hospital length of stay (LOS) were compared between 75 patients before and 75 patients after widespread implementation of the HASS using retrospective chart review and anonymous staff reporting. Interrater reliability was determined by collecting independent HASS scores from blinded staff members after tandem or simultaneous patient assessment. RESULTS Interrater reliability among untrained staff members using the HASS was high. Hospital LOS, rates of adverse events, medical errors, and early transfer to a higher level of care were not significantly different before and after widespread HASS implementation. CONCLUSION The HASS is a reliable asthma severity tool that can be used throughout hospitalization and among multiple clinical providers to trend clinical progress and optimize communication, particularly during times of care handoffs.
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Affiliation(s)
- Sarah C McBride
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kendall McCarty
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jackson Wong
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Broward Health Medical Center, Fort Lauderdale, Florida, USA
| | - Marc Baskin
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Denise Currier
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Vincent W Chiang
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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12
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Management of Children with Acute Asthma Attack: A RAND/UCLA Appropriateness Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312775. [PMID: 34886505 PMCID: PMC8657661 DOI: 10.3390/ijerph182312775] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/25/2021] [Accepted: 11/30/2021] [Indexed: 12/22/2022]
Abstract
Bronchial asthma is the most frequent chronic disease in children and affects up to 20% of the pediatric population, depending on the geographical area. Asthma symptoms vary over time and in intensity, and acute asthma attack can resolve spontaneously or in response to therapy. The aim of this project was to define the care pathway for pediatric patients who come to the primary care pediatrician or Emergency Room with acute asthmatic access. The project was developed in the awareness that for the management of these patients, broad coordination of interventions in the pre-hospital phase and the promotion of timely and appropriate assistance modalities with the involvement of all health professionals involved are important. Through the application of the RAND method, which obliges to discuss the statements derived from the guidelines, there was a clear increase in the concordance in the behavior on the management of acute asthma between primary care pediatricians and hospital pediatricians. The RAND method was found to be useful for the selection of good practices forming the basis of an evidence-based approach, and the results obtained form the basis for further interventions that allow optimizing the care of the child with acute asthma attack at the family and pediatric level. An important point of union between the primary care pediatrician and the specialist hospital pediatrician was the need to share spirometric data, also including the use of new technologies such as teleconsultation. Monitoring the progress of asthma through spirometry could allow the pediatrician in the area to intervene early by modifying the maintenance therapy and help the patient to achieve good control of the disease.
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13
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Halvorson EE, Saha A, Forrest CB, Razzaghi H, Rao S, Phan TLT, Magnusen B, Mejias A, McCrory MC, Wells BJ, Skelton JA, Poehling KA, Tieder JS. Weight Status and Risk of Inpatient Admission for Children With Lower Respiratory Tract Disease. Hosp Pediatr 2021; 11:hpeds.2021-005975. [PMID: 34808672 DOI: 10.1542/hpeds.2021-005975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To identify associations between weight category and hospital admission for lower respiratory tract disease (LRTD), defined as asthma, community-acquired pneumonia, viral pneumonia, or bronchiolitis, among children evaluated in pediatric emergency departments (PEDs). METHODS We performed a retrospective cohort study of children 2 to <18 years of age evaluated in the PED at 6 children's hospitals within the PEDSnet clinical research network from 2009 to 2019. BMI percentile of children was classified as underweight, healthy weight, overweight, and class 1, 2, or 3 obesity. Children with complex chronic conditions were excluded. Mixed-effects multivariable logistic regression was used to assess associations between BMI categories and hospitalization or 7- and 30-day PED revisits, adjusted for covariates (age, sex, race and ethnicity, and payer). RESULTS Among 107 446 children with 218 180 PED evaluations for LRTD, 4.5% had underweight, 56.4% had healthy normal weight, 16.1% had overweight, 14.6% had class 1 obesity, 5.5% had class 2 obesity, and 3.0% had class 3 obesity. Underweight was associated with increased risk of hospital admission compared with normal weight (odds ratio [OR] 1.76; 95% confidence interval [CI] 1.69-1.84). Overweight (OR 0.87; 95% CI 0.85-0.90), class 1 obesity (OR 0.88; 95% CI 0.85-0.91), and class 2 obesity (OR 0.91; 95% CI 0.87-0.96) had negative associations with hospital admission. Class 1 and class 2, but not class 3, obesity had small positive associations with 7- and 30-day PED revisits. CONCLUSIONS We found an inverse relationship between patient weight category and risk for hospital admission in children evaluated in the PED for LRTD.
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Affiliation(s)
| | | | - Christopher B Forrest
- Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hanieh Razzaghi
- Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Suchitra Rao
- Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Thao-Ly Tam Phan
- Department of Pediatrics, Nemours Children's Health System, Wilmington, Delaware
| | - Brianna Magnusen
- Institute for Informatics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Asuncion Mejias
- Division of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | | | | | - Joseph A Skelton
- Departments of Pediatrics
- Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Katherine A Poehling
- Departments of Pediatrics
- Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Joel S Tieder
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
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14
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Owora AH, Tepper RS, Ramsey CD, Becker AB. Decision tree-based rules outperform risk scores for childhood asthma prognosis. Pediatr Allergy Immunol 2021; 32:1464-1473. [PMID: 33938038 DOI: 10.1111/pai.13530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/02/2021] [Accepted: 04/24/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND There are no widely accepted prognostic tools for childhood asthma; this is in part due to the multifactorial and time-dependent nature of mechanisms and risk factors that contribute to asthma development. Our study objective was to develop and evaluate the prognostic performance of conditional inference decision tree-based rules using the Pediatric Asthma Risk Score (PARS) predictors as an alternative to the existing logistic regression-based risk score for childhood asthma prediction at 7 years in a high-risk population. METHODS The Canadian Asthma Primary Prevention Study data were used to develop, compare, and contrast the prognostic performance (area under the curve [AUC], sensitivity, and specificity) of conditional inference tree-based decision rules to the pediatric asthma risk score for the prediction of childhood asthma at 7 years. RESULTS Conditional inference decision tree-based rules have higher prognostic performance (AUC: 0.85; 95% CI: 0.81, 0.88; sensitivity = 47%; specificity = 93%) than the pediatric asthma risk score at an optimal cutoff of ≥6 (AUC: 0.71; 95% CI: 0.67, 0.76; sensitivity = 60%; specificity = 74%). Moreover, the pediatric asthma risk score is not linearly related to asthma risk, and at any given pediatric asthma risk score value, different combinations of its pediatric asthma risk score clinical variables differentially predict asthma risk. CONCLUSION Conditional inference tree-based decision rules could be a useful childhood asthma prognostic tool, providing an alternative way to identify unique subgroups of at-risk children, and insights into associations and effect mechanisms that are suggestive of appropriate tailored preventive interventions. However, the feasibility and effectiveness of such decision rules in clinical practice is warranted.
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Affiliation(s)
- Arthur H Owora
- Department of Epidemiology and Biostatistics, School of Public Health, Bloomington, IN, USA.,Children's Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - Robert S Tepper
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Clare D Ramsey
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Allan B Becker
- Children's Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
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15
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Leung JS. Paediatrics: how to manage acute asthma exacerbations. Drugs Context 2021; 10:dic-2020-12-7. [PMID: 34113386 PMCID: PMC8166724 DOI: 10.7573/dic.2020-12-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/13/2021] [Indexed: 12/11/2022] Open
Abstract
Background Asthma is the most common chronic disease of childhood and a major source of childhood health burden worldwide. These burdens are particularly marked when children experience characteristic ‘symptom flare-ups’ or acute asthma exacerbations (AAEs). AAE are associated with significant health and economic impacts, including acute Emergency Department visits, occasional hospitalizations, and rarely, death. To treat children with AAE, several medications have been studied and used. Methods We conducted a narrative review of the literature with the primary objective of understanding the evidence of their efficacy. We present this efficacy evidence in the context of a general stepwise management pathway for paediatric AAEs. This framework is developed from the combined recommendations of eight established (inter)national paediatric guidelines. Discussion Management of paediatric AAE centres around four major care goals: (1) immediate and objective assessment of AAE severity; (2) prompt and effective medical interventions to decrease respiratory distress and improve oxygenation; (3) appropriate disposition of patient; and (4) safe discharge plans. Several medications are currently recommended with varying efficacies, including heliox, systemic corticosteroids, first-line bronchodilators (salbutamol/albuterol), adjunctive bronchodilators (ipratropium bromide, magnesium sulfate) and second-line bronchodilators (aminophylline, i.v. salbutamol, i.v. terbutaline, epinephrine, ketamine). Care of children with AAE is further enhanced using clinical severity scoring, pathway-driven care and after-event discharge planning. Conclusions AAEs in children are primarily managed by medications supported by a growing body of literature. Continued efforts to study the efficacy of second-line bronchodilators, integrate AAE management with long-term asthma control and provide fair/equitable care are required.
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Affiliation(s)
- James S Leung
- McMaster University, Faculty of Health Sciences, Department of Pediatrics, McMaster Children's Hospital, Hamilton, ON, Canada
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16
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Sills MR, Ozkaynak M, Jang H. Predicting hospitalization of pediatric asthma patients in emergency departments using machine learning. Int J Med Inform 2021; 151:104468. [PMID: 33940479 DOI: 10.1016/j.ijmedinf.2021.104468] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/25/2021] [Accepted: 04/15/2021] [Indexed: 11/26/2022]
Abstract
MOTIVATION The timely identification of patients for hospitalization in emergency departments (EDs) can facilitate efficient use of hospital resources. Machine learning can help the early prediction of ED disposition; however, application of machine learning models requires both computer science skills and domain knowledge. This presents a barrier for those who want to apply machine learning to real-world settings. OBJECTIVES The objective of this study was to construct a competitive predictive model with a minimal amount of human effort to facilitate decisions regarding hospitalization of patients. METHODS This study used the electronic health record data from five EDs in a single healthcare system, including an academic urban children's hospital ED, from January 2009 to December 2013. We constructed two machine learning models by using automated machine learning algorithm (autoML) which allows non-experts to use machine learning model: one with data only available at ED triage, the other adding information available one hour into the ED visit. Random forest and logistic regression were employed as bench-marking models. The ratio of the training dataset to the test dataset was 8:2, and the area under the receiver operating characteristic curve (AUC), accuracy, and F1 were calculated to assess the quality of the models. RESULTS Of the 9,069 ED visits analyzed, the study population was made up of males (62.7 %), median (IQR) age was 6 (4, 10) years, and public insurance coverage (66.0 %). The majority had an Emergency Severity Index score of 3 (52.9 %). The prevalence of hospitalization was 22.5 %. The AUCs were 0.914 and 0.942. AUCs were 0.831 and 0.886 for random forests, and 0.795 and 0.823 for logistic regression. Among the predictors, an outcome at a prior visit, ESI level, time to first medication, and time to triage were the most important features for the prediction of the need for hospitalization. CONCLUSIONS In comparison with the conventional approaches, the use of autoML improved the predictive ability for the need for hospitalization. The findings can optimize ED management, hospital-level resource utilization and improve quality. Furthermore, this approach can support the design of a more effective patient ED flow for pediatric asthma care.
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Affiliation(s)
- Marion R Sills
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Mustafa Ozkaynak
- College of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Hoon Jang
- College of Global Business, Korea University, 2511 Sejong-ro, Sejong, Republic of Korea.
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17
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Lee MO, Sivasankar S, Pokrajac N, Smith C, Lumba‐Brown A. Emergency department treatment of asthma in children: A review. J Am Coll Emerg Physicians Open 2020; 1:1552-1561. [PMID: 33392563 PMCID: PMC7771822 DOI: 10.1002/emp2.12224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
Asthma is the most common chronic illness in children, with >700,000 emergency department (ED) visits each year. Asthma is a respiratory disease characterized by a combination of airway inflammation, bronchoconstriction, bronchial hyperresponsiveness, and variable outflow obstruction, with clinical presentations ranging from mild to life-threatening. Standardized ED treatment can improve patient outcomes, including fewer hospital admissions. Informed by the most recent guidelines, this review focuses on the optimal approach to diagnosis and treatment of children with acute asthma exacerbations who present to the ED.
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Affiliation(s)
- Moon O. Lee
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Shyam Sivasankar
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Nicholas Pokrajac
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Cherrelle Smith
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Angela Lumba‐Brown
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
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18
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Kang CM, Wu ET, Wang CC, Lu F, Chiang BL, Yen TA. Bilevel Positive Airway Pressure ventilation efficiently improves respiratory distress in initial hours treating children with severe asthma exacerbation. J Formos Med Assoc 2019; 119:1415-1421. [PMID: 31806384 DOI: 10.1016/j.jfma.2019.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/06/2019] [Accepted: 11/13/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Treatment of severe asthma exacerbation could be challenging, especially in the initial hours of acute attack when systemic corticosteroid is yet to take effect. In spite of using inhaled agents, the role of non-invasive ventilation (NIV), including Bilevel Positive Airway Pressure (BiPAP), had been addressed recently. METHODS We reviewed 5-year experience in our hospital for records of patients who were admitted to pediatric intensive care unit because of severe asthma attack. The included admission records from 2012 to 2017 were grouped according to BiPAP use (Yes/No). Clinical parameters (heart rate (HR), respiratory rate (RR), SpO2 and serum pCO2) at selected time intervals of treatment were collected for both groups and analyzed. RESULTS We included data of 46 admissions from 33 different patients (24 with BiPAP and 21 without BiPAP.) The BiPAP group had significantly higher initial RR as well as higher severity scores compared with the other group (p < 0.001). The RR improved significantly in the following time intervals in BiPAP group. There was no significant difference in HR between groups in any of the time intervals. The serum pCO2 levels decreased significantly after initiation of ventilation support in the BiPAP group, and SpO2 levels improved significantly for both groups. CONCLUSION BiPAP seemed efficient in improving respiratory rate and oxygenation in our study. It does not seem to cause additional irritation regarding that HR was not increased in BiPAP group compared with non-BiPAP group. Overall, BiPAP ventilation is safe and efficient in treating children with severe asthma attack.
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Affiliation(s)
- Chun-Min Kang
- The Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - En-Ting Wu
- The Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ching-Chia Wang
- The Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Frank Lu
- The Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Bor-Luen Chiang
- The Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan; The Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ting-An Yen
- The Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan.
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19
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Lenko D, Purcell R, Starr M, Bryant PA, South M, Gwee A. Does discharging asthma patients after one hour of treatment if clinically well affect emergency department length of stay. J Paediatr Child Health 2019; 55:1445-1450. [PMID: 30895667 DOI: 10.1111/jpc.14437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 02/06/2019] [Accepted: 02/25/2019] [Indexed: 11/29/2022]
Abstract
AIM Asthma is a major contributor to direct and indirect health-care costs and resource use. In May 2015, the Royal Children's Hospital (RCH) amended its clinical practice guideline for acute asthma management from discharging patients if the anticipated salbutamol requirement was every 3-4 h to discharging patients who were clinically well at 1 h after initial treatment. Our objective was to examine the impact of the new discharge recommendation on emergency department (ED) length of stay (LOS), rates of admission and representation. METHODS We retrospectively audited the case notes of children presenting with mild or moderate asthma to the RCH ED over the equivalent 2-week periods in winter 2014 (pre-implementation of the new guideline) and 2015 (post-implementation). RESULTS A total of 105 patients in 2014 and 92 patients in 2015 were included. In both years, all patients who initially presented with mild or moderate asthma either improved or stayed within the same severity classification at the 1-h assessment. For patients who were clinically well by the 1-h assessment, there was a significant reduction in admissions between 2014 and 2015 (40 vs. 10%, P = 0.001). There was also a reduction for these patients in median LOS from 3 h 13 min in 2014 to 2 h 31 min in 2015 (P = 0.03). In both years, all patients who were moderate at 1 h were admitted. There was no difference in the rate of representation or subsequent deterioration in those patients who were discharged at 1 h between the 2 years. CONCLUSION Early discharge of patients who are clinically well 1 h after initial therapy may be associated with a reduction in LOS and admission rate without an apparent compromise in patient safety. Further evaluation of this intervention is required to determine whether this is a true causal relationship.
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Affiliation(s)
- Debbie Lenko
- Department of General Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Rachael Purcell
- Department of General Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Mike Starr
- Department of General Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Penelope A Bryant
- Department of General Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael South
- Department of General Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Amanda Gwee
- Department of General Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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20
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Ryan KS, Son S, Roddy M, Siraj S, McKinley SD, Nakagawa TA, Sochet AA. Pediatric asthma severity scores distinguish suitable inpatient level of care for children admitted for status asthmaticus. J Asthma 2019; 58:151-159. [PMID: 31608716 DOI: 10.1080/02770903.2019.1680998] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objective: To determine if the Pediatric Asthma Severity Score (PASS) can distinguish "late-rescues" (transfer to the pediatric intensive care unit [PICU] within 24-hours of general pediatric floor admission), "PICU readmissions" (readmission within 24-h after transfer to a lower inpatient level of care), and unplanned 30-day hospital readmission in children admitted with status asthmaticus.Methods: We performed a single center, retrospective cohort study in 328 children admitted for asthma exacerbation aged 5-18 years from May 2015 to October 2017. We sought to determine if PASS values preceding admission from the emergency department or transfer to the general pediatric unit will be greater in children with late rescues and PICU readmissions and if a cutoff PASS values exist to discriminate these events prior to intrafacility transfer.Results: Nine (5%) late-rescues and 5 (3%) PICU readmissions accounted for 14/328 (4%) composite outcomes. PASS values were greater in children with these events (8 [IQR:5-8] vs. 5 [IQR:3-6], p < .01). Logistic regression of PASS on composite outcome yielded an odds ratio of 1.4 (1.1-1.8, p < .01) and ROC curve of PASS on a composite outcome yielded an AUC of 0.74 (0.61-0.87) with a threshold of ≥ 9. Nine (3%) children experienced unplanned 30-day hospital readmissions but PASS preceding hospital discharge was neither discriminative nor associated with hospital readmission.Conclusions: PASS values ≥ 9 identify children at increased risk for late-rescue and PICU readmission. Applied with traditionally criteria for selection of inpatient level of care, PASS may assist providers in reducing acute inpatient disposition errors.
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Affiliation(s)
- Kelsey S Ryan
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Department of Pediatrics, University of South Florida, Tampa, FL, USA
| | - Sorany Son
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Meghan Roddy
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Shaila Siraj
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Department of Pediatrics, University of South Florida, Tampa, FL, USA.,School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Thomas A Nakagawa
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Anthony A Sochet
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Department of Pediatrics, University of South Florida, Tampa, FL, USA.,School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Al-Shamrani A, Al-Harbi AS, Bagais K, Alenazi A, Alqwaiee M. Management of asthma exacerbation in the emergency departments. Int J Pediatr Adolesc Med 2019; 6:61-67. [PMID: 31388549 PMCID: PMC6676463 DOI: 10.1016/j.ijpam.2019.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Al-Moamary MS, Alhaider SA, Alangari AA, Al Ghobain MO, Zeitouni MO, Idrees MM, Alanazi AF, Al-Harbi AS, Yousef AA, Alorainy HS, Al-Hajjaj MS. The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2019; 14:3-48. [PMID: 30745934 PMCID: PMC6341863 DOI: 10.4103/atm.atm_327_18] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.
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Affiliation(s)
- Mohamed S Al-Moamary
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullah A Alangari
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed O Al Ghobain
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed O Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Majdy M Idrees
- Respiratory Division, Department of Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah F Alanazi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Adel S Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hassan S Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed S Al-Hajjaj
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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23
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Mahmoud SH. Assessment Considerations in Pediatric Patients. PATIENT ASSESSMENT IN CLINICAL PHARMACY 2019. [PMCID: PMC7123523 DOI: 10.1007/978-3-030-11775-7_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pharmacy assessment of pediatric patients is similar in many ways to that of adults; however there are many specific nuances that need to be considered in addition to the typical aspects included in an adult assessment. There is a lack of pediatric-specific medication research and a much higher rate of “off label” medication use, so children are at higher risk of medication errors and related harm. Pharmacokinetic differences and other age-related differences result in highly variable responses to medications throughout childhood. Pharmacists need to be aware of this variability and use every patient encounter as an opportunity for assessment of many aspects of medication including dose, formulation, administration, and indication. Infants and children also have physiological differences that need to be considered especially when assessing efficacy, toxicity, and the patient’s overall response to medications through physical exam or use of laboratory values. Lastly, a lack of appropriate medication formulations for children creates a requirement for pharmacists to specifically assess the formulations, measurement, and administration of pediatric medications. This chapter provides an approach to pediatric assessment, highlights common sources of error, and provides strategies for managing pediatric medications.
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Patel SJ, Chamberlain DB, Chamberlain JM. A Machine Learning Approach to Predicting Need for Hospitalization for Pediatric Asthma Exacerbation at the Time of Emergency Department Triage. Acad Emerg Med 2018; 25:1463-1470. [PMID: 30382605 DOI: 10.1111/acem.13655] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Pediatric asthma is a leading cause of emergency department (ED) utilization and hospitalization. Earlier identification of need for hospital-level care could triage patients more efficiently to high- or low-resource ED tracks. Existing tools to predict disposition for pediatric asthma use only clinical data, perform best several hours into the ED stay, and are static or score-based. Machine learning offers a population-specific, dynamic option that allows real-time integration of available nonclinical data at triage. Our objective was to compare the performance of four common machine learning approaches, incorporating clinical data available at the time of triage with information about weather, neighborhood characteristics, and community viral load for early prediction of the need for hospital-level care in pediatric asthma. METHODS Retrospective analysis of patients ages 2 to 18 years seen at two urban pediatric EDs with asthma exacerbation over 4 years. Asthma exacerbation was defined as receiving both albuterol and systemic corticosteroids. We included patient features, measures of illness severity available in triage, weather features, and Centers for Disease Control and Prevention influenza patterns. We tested four models: decision trees, LASSO logistic regression, random forests, and gradient boosting machines. For each model, 80% of the data set was used for training and 20% was used to validate the models. The area under the receiver operating characteristic (AUC) curve was calculated for each model. RESULTS There were 29,392 patients included in the analyses: mean (±SD) age of 7.0 (±4.2) years, 42% female, 77% non-Hispanic black, and 76% public insurance. The AUCs for each model were: decision tree 0.72 (95% confidence interval [CI] = 0.66-0.77), logistic regression 0.83 (95% CI = 0.82-0.83), random forests 0.82 (95% CI = 0.81-0.83), and gradient boosting machines 0.84 (95% CI = 0.83-0.85). In the lowest decile of risk, only 3% of patients required hospitalization; in the highest decile this rate was 100%. After patient vital signs and acuity, age and weight, followed by socioeconomic status (SES) and weather-related features, were the most important for predicting hospitalization. CONCLUSIONS Three of the four machine learning models performed well with decision trees preforming the worst. The gradient boosting machines model demonstrated a slight advantage over other approaches at predicting need for hospital-level care at the time of triage in pediatric patients presenting with asthma exacerbation. The addition of weight, SES, and weather data improved the performance of this model.
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Affiliation(s)
- Shilpa J. Patel
- Division of Emergency Medicine Children's National Health System Washington DC UK
| | | | - James M. Chamberlain
- Division of Emergency Medicine Children's National Health System Washington DC UK
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25
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Jean T, Yang SJ, Crawford WW, Takahashi SH, Sheikh J. Development of a pediatric asthma predictive index for hospitalization. Ann Allergy Asthma Immunol 2018; 122:283-288. [PMID: 30476547 DOI: 10.1016/j.anai.2018.11.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/31/2018] [Accepted: 11/19/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Variation in emergency department (ED) management for asthma exacerbation leads to disparities in care. Current asthma severity scores are insufficient to be used for hospitalization decisions. OBJECTIVE To develop and internally validate an asthma predictive index for hospitalization (APIH) to guide practitioners in their admission decision for children with asthma exacerbations. METHODS Data were collected from 12,066 children between 5 and 18 years old diagnosed with asthma exacerbation in the ED. Epidemiologic findings, number of inhaled corticosteroid canisters, short-acting β-blocker canisters, oral steroids, coexisting atopy, family history of atopy, insurance, and prior asthma ED visits or hospitalizations were compared between patients hospitalized and discharged. We used univariate analysis and multivariate analysis to determine the best predictor variables for hospitalization. Our study internally validated the prediction index to estimate future performance of the prediction rule. RESULTS The highest risk factors associated with asthma hospitalization from the ED are oxygen saturation less than 94%, respiratory rate greater than 31/min, history of pneumonia, and asthma ED visits in past 12 months. With a reduced predictive model that combined these risk factors, the odds ratio was 44.9 (95% CI, 32.8-61.4), which is extremely significant. Our C index of discrimination of 0.77 was similar to the validation C index of 0.78, which confirms a solid prediction model. CONCLUSION We have developed and internally validated a pediatric hospitalization prediction index for acute asthma exacerbation in the ED. Further studies are needed to externally validate the APIH before its implementation into clinical practice.
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Affiliation(s)
- Tiffany Jean
- Department of Allergy and Immunology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California.
| | - Su-Jau Yang
- Department of Research and Evaluation, Kaiser Permanente, Los Angeles, California
| | - William W Crawford
- Department of Allergy and Immunology, Kaiser Permanente South Bay Medical Center, Harbor City, California
| | - Scott H Takahashi
- Department of Pediatric Ambulatory Care Pharmacy, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Javed Sheikh
- Department of Allergy and Immunology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
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26
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Indinnimeo L, Chiappini E, Miraglia Del Giudice M. Guideline on management of the acute asthma attack in children by Italian Society of Pediatrics. Ital J Pediatr 2018; 44:46. [PMID: 29625590 PMCID: PMC5889573 DOI: 10.1186/s13052-018-0481-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 03/21/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Acute asthma attack is a frequent condition in children. It is one of the most common reasons for emergency department (ED) visit and hospitalization. Appropriate care is fundamental, considering both the high prevalence of asthma in children, and its life-threatening risks. Italian Society of Pediatrics recently issued a guideline on the management of acute asthma attack in children over age 2, in ambulatory and emergency department settings. METHODS The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was adopted. A literature search was performed using the Cochrane Library and Medline/PubMed databases, retrieving studies in English or Italian and including children over age 2 year. RESULTS Inhaled ß2 agonists are the first line drugs for acute asthma attack in children. Ipratropium bromide should be added in moderate/severe attacks. Early use of systemic steroids is associated with reduced risk of ED visits and hospitalization. High doses of inhaled steroids should not replace systemic steroids. Aminophylline use should be avoided in mild/moderate attacks. Weak evidence supports its use in life-threatening attacks. Epinephrine should not be used in the treatment of acute asthma for its lower cost / benefit ratio, compared to β2 agonists. Intravenous magnesium solphate could be used in children with severe attacks and/or forced expiratory volume1 (FEV1) lower than 60% predicted, unresponsive to initial inhaled therapy. Heliox could be administered in life-threatening attacks. Leukotriene receptor antagonists are not recommended. CONCLUSIONS This Guideline is expected to be a useful resource in managing acute asthma attacks in children over age 2.
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Affiliation(s)
- Luciana Indinnimeo
- Pediatric Department "Sapienza" University of Rome, Policlinico Umberto I Viale Regina Elena 324, 00161, Rome, Italy.
| | - Elena Chiappini
- Pediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - Michele Miraglia Del Giudice
- Department of Woman and Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
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Patel SJ, Arnold DH, Topoz I, Sills MR. Literature Review: Prediction Modeling of Emergency Department Disposition Decisions for Children with Acute Asthma Exacerbations. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
OBJECTIVES We aimed to evaluate the seasonal variations of acute asthma presentation in children and the utility of the pediatric asthma score (PAS) and its components in early admission prediction. METHODS As part of a randomized controlled trial addressing the clinical efficacy of budesonide nebulization in the treatment of acute asthma in children, the PAS was measured at baseline, 1st, 2nd, 3rd, and 4th h from the start of medications. Decision of admission was taken at or beyond the 2nd h. RESULTS Out of a total 906 emergency department (ED) visits with moderate-to-severe acute asthma, 157 children were admitted. June to September had the lowest number of visits. The admission-to-discharge ratio varied throughout the year. During the ED stay, between baseline and 3rd h, admission predictability of the total score improved progressively with a small difference between the 2nd and 3rd h. The total score remained the strongest predictor of admission at every time point compared to its individual components. The drop of PAS from baseline to the 2nd h was not a good predictor of admission. Oxygen saturation (OS) and respiratory rate (RR) had relatively higher predictability than other components. CONCLUSIONS Decision of admission could be made to many children with moderate-to-severe acute asthma at the 2nd h of ED stay based on their total PAS. OS and RR should be part of any scoring system to evaluate acute asthma in children.
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Affiliation(s)
- Maan Alherbish
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khalid F Mobaireek
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah A Alangari
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Johnson MD, Nkoy FL, Sheng X, Greene T, Stone BL, Garvin J. Direct concurrent comparison of multiple pediatric acute asthma scoring instruments. J Asthma 2017; 54:741-753. [PMID: 27831833 PMCID: PMC5425314 DOI: 10.1080/02770903.2016.1258081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Appropriate delivery of Emergency Department (ED) treatment to children with acute asthma requires clinician assessment of acute asthma severity. Various clinical scoring instruments exist to standardize assessment of acute asthma severity in the ED, but their selection remains arbitrary due to few published direct comparisons of their properties. Our objective was to test the feasibility of directly comparing properties of multiple scoring instruments in a pediatric ED. METHODS Using a novel approach supported by a composite data collection form, clinicians categorized elements of five scoring instruments before and after initial treatment for 48 patients 2-18 years of age with acute asthma seen at the ED of a tertiary care pediatric hospital ED from August to December 2014. Scoring instruments were compared for inter-rater reliability between clinician types and their ability to predict hospitalization. RESULTS Inter-rater reliability between clinician types was not different between instruments at any point and was lower (weighted kappa range 0.21-0.55) than values reported elsewhere. Predictive ability of most instruments for hospitalization was higher after treatment than before treatment (p < 0.05) and may vary between instruments after treatment (p = 0.054). CONCLUSIONS We demonstrate the feasibility of comparing multiple clinical scoring instruments simultaneously in ED clinical practice. Scoring instruments had higher predictive ability for hospitalization after treatment than before treatment and may differ in their predictive ability after initial treatment. Definitive conclusions about the best instrument or meaningful comparison between instruments will require a study with a larger sample size.
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Affiliation(s)
- Michael D. Johnson
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Flory L. Nkoy
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
- Department of Biomedical Informatics, University of Utah School of
Medicine, Suite 140, 421 Wakara Way, Salt Lake City, UT 84108, USA
| | - Xiaoming Sheng
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Tom Greene
- Department of Population Health Sciences, University of Utah School
of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Bryan L. Stone
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Jennifer Garvin
- Department of Biomedical Informatics, University of Utah School of
Medicine, Suite 140, 421 Wakara Way, Salt Lake City, UT 84108, USA
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30
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Maue DK, Krupp N, Rowan CM. Pediatric asthma severity score is associated with critical care interventions. World J Clin Pediatr 2017; 6:34-39. [PMID: 28224093 PMCID: PMC5296627 DOI: 10.5409/wjcp.v6.i1.34] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 10/09/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To determine if a standardized asthma severity scoring system (PASS) was associated with the time spent on continuous albuterol and length of stay in the pediatric intensive care unit (PICU).
METHODS This is a single center, retrospective chart review study at a major children’s hospital in an urban location. To qualify for this study, participants must have been admitted to the PICU with a diagnosis of status asthmaticus. There were a total of 188 participants between the ages of two and nineteen, excluding patients receiving antibiotics for pneumonia. PASS was calculated upon PICU admission. Subjects were put into one of three categories based on PASS: ≤ 7 (mild), 8-11 (moderate), and ≥ 12 (severe). The groups were compared based on different variables, including length of continuous albuterol and PICU stay.
RESULTS The age distribution across all groups was similar. The median length of continuous albuterol was longest in the severe group with a duration of 21.5 h (11.5-27.5), compared to 15 (7.75-23.75) and 10 (5-15) in the moderate and mild groups, respectively (P = 0.001). The length of stay was longest in the severe group, with a stay of 35.6 h (22-49) compared to 26.5 (17-30) and 17.6 (12-29) in the moderate and mild groups, respectively (P = 0.001).
CONCLUSION A higher PASS is associated with a longer time on continuous albuterol, an increased likelihood to require noninvasive ventilation, and a longer stay in the ICU. This may help safely distribute asthmatics to lower and higher levels of care in the future.
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Ozdemir A, Dogruel D, Yilmaz O. Oxygen saturation/minute heart rate index: Simple lung function test for children. Pediatr Int 2017; 59:209-212. [PMID: 27377817 DOI: 10.1111/ped.13081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 06/05/2016] [Accepted: 06/28/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The severity of airway obstruction can be accurately determined on spirometry in children with asthma. Other assessments may include peak expiratory flow and pulse oximetry. In the present study, we evaluated the validity and reliability of oxygen saturation/minute heart rate (SpO2 /MHR) index in the prediction of degree of severe airway obstruction in children with asthma. METHODS This was a retrospective study of children aged 7-17 followed for asthma at Mersin Women and Children's Hospital. The study compared SpO2 /MHR ratio with forced expiratory volume in 1 s (FEV1 ) measured on spirometry, an important indicator of small airway obstruction. A total of 296 patients were included in the study, and classified either as having normal FEV1 (FEV1 > 80% of predicted, n = 178) or severely reduced FEV1 (FEV1 < 60% of predicted, n = 118). Positive and negative predictive values (PPV and NPV), sensitivity and specificity of SpO2 /MHR index in predicting low FEV1 were calculated on receiver operating characteristics analysis. RESULTS An SpO2 /MHR ratio cut-off <0.90 was associated with a PPV of 83.14%, NPV of 71.77%, sensitivity of 80.34% and specificity of 75.42% in predicting low FEV1 . CONCLUSIONS SpO2 /MHR ratio appears to be a highly useful index to assess airway obstruction in older children with asthma. Thus, it can be used as a marker of airway obstruction severity when spirometry is not available.
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Affiliation(s)
- Ali Ozdemir
- Pediatric Pulmonary Section, Department of Pediatrics, Mersin Women and Children's Hospital, Halkkent, Mersin, Turkey
| | - Dilek Dogruel
- Pediatric Allergy and Immunology Section, Department of Pediatrics, Baskent University, Adana, Turkey
| | - Ozlem Yilmaz
- Pediatric Allergy and Immunology Section, Department of Pediatrics, Mersin Women and Children's Hospital, Halkkent, Mersin, Turkey
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Rutman L, Atkins RC, Migita R, Foti J, Spencer S, Lion KC, Wright DR, Leu MG, Zhou C, Mangione-Smith R. Modification of an Established Pediatric Asthma Pathway Improves Evidence-Based, Efficient Care. Pediatrics 2016; 138:peds.2016-1248. [PMID: 27940683 DOI: 10.1542/peds.2016-1248] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In September 2011, an established pediatric asthma pathway at a tertiary care children's hospital underwent significant revision. Modifications included simplification of the visual layout, addition of evidence-based recommendations regarding medication use, and implementation of standardized admission criteria. The objective of this study was to determine the impact of the modified asthma pathway on pathway adherence, percentage of patients receiving evidence-based care, length of stay, and cost. METHODS Cases were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Data were analyzed for 24 months before and after pathway modification. Statistical process control was used to examine changes in processes of care, and interrupted time series was used to examine outcome measures, including length of stay and cost in the premodification and postmodification periods. RESULTS A total of 5584 patients were included (2928 premodification; 2656 postmodification). Pathway adherence was high (79%-88%) throughout the study period. The percentage of patients receiving evidence-based care improved after pathway modification, and the results were sustained for 2 years. There was also improved efficiency, with a 30-minute (10%) decrease in emergency department length of stay for patients admitted with asthma (P = .006). There was a nominal (<10%) increase in costs of asthma care for patients in the emergency department (P = .04) and no change for those admitted to the hospital. CONCLUSIONS Modification of an existing pediatric asthma pathway led to sustained improvement in provision of evidence-based care and patient flow without adversely affecting costs. Our results suggest that continuous re-evaluation of established clinical pathways can lead to changes in provider practices and improvements in patient care.
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Affiliation(s)
- Lori Rutman
- University of Washington, Seattle, Washington; .,Seattle Children's Hospital, Seattle, Washington; and
| | | | - Russell Migita
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | - Jeffrey Foti
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | | | - K Casey Lion
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | - Davene R Wright
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | - Michael G Leu
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | - Chuan Zhou
- University of Washington, Seattle, Washington
| | - Rita Mangione-Smith
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
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Korang SK, Feinberg J, Wetterslev J, Jakobsen JC. Non-invasive positive pressure ventilation for acute asthma in children. Cochrane Database Syst Rev 2016; 9:CD012067. [PMID: 27687114 PMCID: PMC6457810 DOI: 10.1002/14651858.cd012067.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Asthma is one of the most common reasons for hospital admission among children and constitutes a significant economic burden. Use of non-invasive positive pressure ventilation (NPPV) in the care of children with acute asthma has increased even though evidence supporting the intervention has been considered weak and clinical guidelines do not recommend the intervention. NPPV might be an effective intervention for acute asthma, but no systematic review has been conducted to assess the effects of NPPV as an add-on therapy to usual care in children with acute asthma. OBJECTIVES To assess the benefits and harms of NPPV as an add-on therapy to usual care (e.g. bronchodilators and corticosteroids) in children with acute asthma. SEARCH METHODS We identified trials from the Cochrane Airways Group Specialised Register (CAGR). The Register contains trial reports identified through systematic searches of bibliographic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED and PsycINFO, and by handsearching of respiratory journals and meeting abstracts. We also conducted a search of ClinicalTrials.gov (www.ClinicalTrials.gov) and the WHO trials portal (www.who.int/ictrp/en/). We searched all databases from their inception to February 2016, with no restriction on language of publication. SELECTION CRITERIA We included randomised clinical trials (RCTs) assessing NPPV as add-on therapy to usual care versus usual care for children (age < 18 years) hospitalised for an acute asthma attack. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts. We retrieved all relevant full-text study reports, independently screened the full text, identified trials for inclusion and identified and recorded reasons for exclusion of ineligible trials. We resolved disagreements through discussion or, if required, consulted a third review author. We recorded the selection process in sufficient detail to complete a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flow diagram and 'Characteristics of excluded studies' table. We identified the risk of bias of included studies to reduce the risk of systematic error. We contacted relevant study authors when data were missing. MAIN RESULTS We included two RCTs that randomised 20 participants to NPPV and 20 participants to control. We assessed both studies as having high risk of bias; both trials assessed effects of bilateral positive airway pressure (BiPAP). Neither trial used continuous positive airway pressure (CPAP). Controls received standard care. Investigators reported no deaths and no serious adverse events (Grades of Recommendation, Assessment, Development and Evaluation (GRADE): very low quality of evidence due to serious risk of bias and serious imprecision of results). Both trials showed a statistically significant reduction in symptom score. One trial did not report a standard deviation (SD), but by using an estimated SD, we found a statistically significantly reduced asthma symptom score (mean difference (MD) -2.50, 95% confidence interval (CI) -4.70 to -0.30, P = 0.03, 19 participants, GRADE: very low quality of evidence). In the other trial, NPPV was associated with a lower total symptom score (5.6 vs 1.9, 16 participants, very low quality of evidence) before cross-over, but investigators did not report an SD, nor could it be estimated from the first phase of the trial, before the cross-over. These gains could be clinically relevant, as a reduction of three or more points in symptom score is considered a clinically meaningful change. Researchers documented five dropouts (12.5%), four of which were due to intolerance to NPPV, and one to respiratory failure requiring intubation. Owing to insufficient reporting in the latter trial and use of different scoring systems, it was not possible to conduct a meta-analysis nor a Trial Sequential Analysis. AUTHORS' CONCLUSIONS Current evidence does not permit confirmation or rejection of the effects of NPPV for acute asthma in children. Large RCTs with low risk of bias are warranted.
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Affiliation(s)
- Steven Kwasi Korang
- Holbaek SygehusPediatric DepartmentSmedelundsgade 60HolbaekDenmark4300
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchCopenhagenDenmark
| | - Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchCopenhagenDenmark
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchCopenhagenDenmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenSjællandDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
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Rutman L, Migita R, Spencer S, Kaplan R, Klein EJ. Standardized Asthma Admission Criteria Reduce Length of Stay in a Pediatric Emergency Department. Acad Emerg Med 2016; 23:289-96. [PMID: 26728418 DOI: 10.1111/acem.12890] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/10/2015] [Accepted: 10/11/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Asthma is the most common chronic illness in children and accounts for > 600,000 emergency department (ED) visits each year. Reducing ED length of stay (LOS) for moderate to severe asthmatics improves ED throughput and patient care for this high-risk population. The objective of this study was to determine the impact of adding standardized, respiratory score-based admission criteria to an asthma pathway on ED LOS for admitted patients, time to bed request, overall percentage of admitted asthmatics, inpatient LOS, and percentage of pediatric intensive care unit (PICU) admissions. METHODS This was a retrospective study of a quality improvement intervention. Statistical process control methodologies were used to analyze measures 15 months before and after implementation of a modified asthma pathway (June 2010 to December 2012; pathway modification September 2011). RESULTS A total of 3,688 patients aged 1 through 18 years who presented to the ED with an asthma exacerbation during the study period were included. Patients were excluded if they were not eligible for the asthma pathway. Patient characteristics were similar before and after the intervention. Mean ED LOS and time to bed request for admitted asthmatics both decreased by 30 minutes. There was no change in percentage of asthma admissions (34%), mean inpatient LOS (1.4 days), or percentage of PICU admissions (2%). CONCLUSIONS Standardizing care for asthma patients to include objective admission criteria early in the ED course may optimize patient care and improve ED flow.
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Affiliation(s)
- Lori Rutman
- University of Washington; Seattle WA
- Seattle Children's Hospital; Seattle WA
| | - Russell Migita
- University of Washington; Seattle WA
- Seattle Children's Hospital; Seattle WA
| | | | - Ron Kaplan
- University of Washington; Seattle WA
- Seattle Children's Hospital; Seattle WA
| | - Eileen J. Klein
- University of Washington; Seattle WA
- Seattle Children's Hospital; Seattle WA
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Korang SK, Feinberg J, Wetterslev J, Jakobsen JC. Non-invasive positive pressure ventilation for acute asthma in children. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Al-Moamary MS, Alhaider SA, Idrees MM, Al Ghobain MO, Zeitouni MO, Al-Harbi AS, Yousef AA, Al-Matar H, Alorainy HS, Al-Hajjaj MS. The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2016; 11:3-42. [PMID: 26933455 PMCID: PMC4748613 DOI: 10.4103/1817-1737.173196] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 12/21/2022] Open
Abstract
This is an updated guideline for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have guidelines that are up to date, simple to understand and easy to use by nonasthma specialists, including primary care and general practice physicians. SINA approach is mainly based on symptom control and assessment of risk as it is the ultimate goal of treatment. The new SINA guidelines include updates of acute and chronic asthma management, with more emphasis on the use of asthma control in the management of asthma in adults and children, inclusion of a new medication appendix, and keeping consistency on the management at different age groups. The section on asthma in children is rewritten and expanded where the approach is stratified based on the age. The guidelines are constructed based on the available evidence, local literature, and the current situation in Saudi Arabia. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.
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Affiliation(s)
- Mohamed S. Al-Moamary
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A. Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Majdy M. Idrees
- Department of Medicine, Pulmonary Division, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed O. Al Ghobain
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed O. Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Adel S. Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, University of Dammam, Dammam, Saudi Arabia
| | - Hussain Al-Matar
- Department of Medicine, Imam Abdulrahman Al Faisal Hospital, Dammam, Saudi Arabia
| | - Hassan S. Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed S. Al-Hajjaj
- Department of Medicine, Respiratory Division, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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