1
|
Kumar J, Kumar P, Goyal JP, Rajvanshi N, Prabhakaran K, Meena J, Gupta A. Role of nebulised magnesium sulfate in treating acute asthma in children: a systematic review and meta-analysis. BMJ Paediatr Open 2024; 8:e002638. [PMID: 38782483 PMCID: PMC11116886 DOI: 10.1136/bmjpo-2024-002638] [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: 03/13/2024] [Accepted: 04/05/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVES To review the efficacy of nebulised magnesium sulfate (MgSO4) in acute asthma in children. METHODS The authors searched Medline, Embase, Web of Science and Cochrane Library for randomised controlled trials (RCTs) published until 15 December 2023. RCTs were included if they compared the efficacy and safety of nebulised MgSO4 as a second-line agent in children presenting with acute asthma exacerbation. A random-effects meta-analysis was performed, and the Risk of Bias V.2 tool was used to assess the biases among them. RESULTS 10 RCTs enrolling 2301 children with acute asthma were included. All trials were placebo controlled and administered nebulised MgSO4/placebo and salbutamol (±ipratropium bromide). There was no significant difference in Composite Asthma Severity Score between the two groups (6 RCTs, 1953 participants; standardised mean difference: -0.09; 95% CI: -0.2 to +0.02, I2=21%). Children in the MgSO4 group have significantly better peak expiratory flow rate (% predicted) than the control group (2 RCTs, 145 participants; mean difference: 19.3; 95% CI: 8.9 to 29.8; I2=0%). There was no difference in the need for hospitalisation, intensive care unit admission or duration of hospital stay. Adverse events were minor, infrequent (7.3%) and similar among the two groups. CONCLUSIONS There is low-certainty evidence that nebulised MgSO4 as an add-on second-line therapy for acute asthma in children does not reduce asthma severity or a need for hospitalisation. However, it was associated with slightly better lung functions. The current evidence does not support the routine use of nebulised MgSO4 in paediatric acute asthma management. PROSPERO REGISTRATION NUMBER CRD42022373692.
Collapse
Affiliation(s)
- Jogender Kumar
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prawin Kumar
- Department of Pediatrics, AIIMS Jodhpur, Jodhpur, Rajasthan, India
| | | | - Nikhil Rajvanshi
- Department of Pediatrics, AIIMS Jodhpur, Jodhpur, Rajasthan, India
| | | | - Jitendra Meena
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Gupta
- Department of Paediatric Respiratory Medicine, King's College Hospital NHS Trust, London, UK
- Department of Paediatric Respiratory Medicine, King's college London, London, UK
| |
Collapse
|
2
|
Cooper AZ, Jain S, Santhosh L, Carlos WG. Eye on the Prize: Patient Outcomes Research in Medical Education. ATS Sch 2024; 5:8-18. [PMID: 38585575 PMCID: PMC10995853 DOI: 10.34197/ats-scholar.2023-0046ps] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/18/2023] [Indexed: 04/09/2024] Open
Abstract
The overarching goal of medical education is to train clinicians who achieve and maintain competence in patient care. Although the field of medical education research has acknowledged the importance of education on clinical practices and outcomes, most research endeavors continue to focus on learner-centered outcomes, such as knowledge and attitudes. The absence of clinical and patient-centered outcomes in pulmonary and critical care medicine medical education research has been attributed to barriers at multiple levels, including financial, methodological, and practical considerations. This Perspective explores clinical outcomes relevant to pulmonary and critical care medicine educational research and offers strategies and solutions that educators can use to accomplish what many consider the "prize" of medical education research: an understanding of how our educational initiatives impact the health of patients.
Collapse
Affiliation(s)
- Avraham Z. Cooper
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lekshmi Santhosh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California–San Francisco, San Francisco, California; and
| | - W. Graham Carlos
- Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
3
|
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: 0] [Impact Index Per Article: 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.
Collapse
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
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Walsh S, Pan S, Sheng Y, Kloprogge F, Standing JF, Anderson BJ, Ramnarayan P. Optimising intravenous salbutamol in children: a phase 2 study. Arch Dis Child 2023; 108:316-322. [PMID: 36581395 DOI: 10.1136/archdischild-2022-324008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 12/11/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The β2-agonists such as salbutamol are the mainstay of asthma management. Pharmacokinetic-pharmacodynamic (PKPD) models to guide paediatric dosing are lacking. We explored the relationship between salbutamol dose, serum concentration, effectiveness and adverse effects in children by developing a PKPD model. DESIGN A prospective cohort study of children admitted to hospital with acute asthma, who received intravenous salbutamol. SETTING Children were recruited in two cohorts: the emergency departments of two London hospitals or those retrieved by the Children's Acute Transport Service to three London paediatric intensive care units. PATIENTS Patients were eligible if aged 1-15 years, admitted for acute asthma and about to receive or receiving intravenous salbutamol. INTERVENTIONS Treatment was according to local policy. Serial salbutamol plasma levels were taken. Effectiveness measurements were recorded using the Paediatric Asthma Severity Score (PASS). Toxicity measurements included lactate, pH, glucose, heart rate, blood pressure and arrhythmias. PKPD modelling was performed with non-linear mixed-effect models. MAIN OUTCOMES Fifty-eight children were recruited with 221 salbutamol concentration measurements from 54 children. Median (range) age was 2.9 (1.1-15.2) years, and weight was 13.6 (8-57.3) kg. Ninety-five PASS measurements and 2078 toxicity measurements were obtained. RESULTS A two-compartment PK model adequately described the time course of salbutamol-plasma concentrations. An EMAX (maximum drug effect) concentration-effect relationship described PASS and toxicity measures. PKPD simulations showed an infusion of 0.5 µg/kg/min (maximum 20 µg/min) for 4 hours after bolus achieves >90% maximal bronchodilation for 12 hours. CONCLUSIONS A paediatric PKPD model for salbutamol is described. An infusion of 0.5 µg/kg/min after bolus achieves effective bronchodilation. Higher rates are associated with greater tachycardia and hyperglycaemia.
Collapse
Affiliation(s)
- Sandra Walsh
- Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Shan Pan
- Infection, Immunity and Inflammation Section, UCL Great Ormond Street Institute of Child Health Library, London, UK
| | - Yucheng Sheng
- Infection, Immunity and Inflammation Section, UCL Great Ormond Street Institute of Child Health Library, London, UK
| | - Frank Kloprogge
- Institute for Global Health, University College London, London, UK
| | - Joe F Standing
- Infection, Immunity and Inflammation Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Hernandez-Pacheco N, Gorenjak M, Li J, Repnik K, Vijverberg SJ, Berce V, Jorgensen A, Karimi L, Schieck M, Samedy-Bates LA, Tavendale R, Villar J, Mukhopadhyay S, Pirmohamed M, Verhamme KMC, Kabesch M, Hawcutt DB, Turner S, Palmer CN, Tantisira KG, Burchard EG, Maitland-van der Zee AH, Flores C, Potočnik U, Pino-Yanes M. Identification of ROBO2 as a Potential Locus Associated with Inhaled Corticosteroid Response in Childhood Asthma. J Pers Med 2021; 11:jpm11080733. [PMID: 34442380 PMCID: PMC8399629 DOI: 10.3390/jpm11080733] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 07/26/2021] [Indexed: 12/15/2022] Open
Abstract
Inhaled corticosteroids (ICS) are the most common asthma controller medication. An important contribution of genetic factors in ICS response has been evidenced. Here, we aimed to identify novel genetic markers involved in ICS response in asthma. A genome-wide association study (GWAS) of the change in lung function after 6 weeks of ICS treatment was performed in 166 asthma patients from the SLOVENIA study. Patients with an improvement in lung function ≥8% were considered as ICS responders. Suggestively associated variants (p-value ≤ 5 × 10−6) were evaluated in an independent study (n = 175). Validation of the association with asthma exacerbations despite ICS use was attempted in European (n = 2681) and admixed (n = 1347) populations. Variants previously associated with ICS response were also assessed for replication. As a result, the SNP rs1166980 from the ROBO2 gene was suggestively associated with the change in lung function (OR for G allele: 7.01, 95% CI: 3.29–14.93, p = 4.61 × 10−7), although this was not validated in CAMP. ROBO2 showed gene-level evidence of replication with asthma exacerbations despite ICS use in Europeans (minimum p-value = 1.44 × 10−5), but not in admixed individuals. The association of PDE10A-T with ICS response described by a previous study was validated. This study suggests that ROBO2 could be a potential novel locus for ICS response in Europeans.
Collapse
Affiliation(s)
- Natalia Hernandez-Pacheco
- Research Unit, Hospital Universitario N.S. de Candelaria, Universidad de La Laguna, Carretera General del Rosario 145, 38010 Santa Cruz de Tenerife, Spain;
- Genomics and Health Group, Department of Biochemistry, Microbiology, Cell Biology and Genetics, Universidad de La Laguna, Avenida Astrofísico Francisco Sánchez s/n, Faculty of Science, Apartado 456, 38200 San Cristóbal de La Laguna, Spain;
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Avenida de Monforte de Lemos, 5, 28029 Madrid, Spain;
- Correspondence: (N.H.-P.); (U.P.); Tel.: +46-0702983315 (N.H.-P.); +386-22345854 (U.P.)
| | - Mario Gorenjak
- Center for Human Molecular Genetics and Pharmacogenomics, Faculty of Medicine, University of Maribor, Taborska Ulica 8, 2000 Maribor, Slovenia; (M.G.); (K.R.); (V.B.)
| | - Jiang Li
- The Channing Division of Network Medicine, Department of Medicine, Brigham & Women’s Hospital and Harvard Medical School, 75 Francis St, Boston, MA 02115, USA; (J.L.); (K.G.T.)
| | - Katja Repnik
- Center for Human Molecular Genetics and Pharmacogenomics, Faculty of Medicine, University of Maribor, Taborska Ulica 8, 2000 Maribor, Slovenia; (M.G.); (K.R.); (V.B.)
- Laboratory for Biochemistry, Molecular Biology, and Genomics, Faculty of Chemistry and Chemical Engineering, University of Maribor, Smetanova ulica 17, 2000 Maribor, Slovenia
| | - Susanne J. Vijverberg
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (S.J.V.); (A.H.M.-v.d.Z.)
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Princetonplein 5, 3584 CC Utrecht, The Netherlands
- Department of Pediatric Respiratory Medicine and Allergy, Emma’s Children Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Vojko Berce
- Center for Human Molecular Genetics and Pharmacogenomics, Faculty of Medicine, University of Maribor, Taborska Ulica 8, 2000 Maribor, Slovenia; (M.G.); (K.R.); (V.B.)
- Department of Pediatrics, University Medical Centre Maribor, Ljubljanska Ulica 5, 2000 Maribor, Slovenia
| | - Andrea Jorgensen
- Department of Biostatistics, University of Liverpool, Crown Street, Liverpool L69 3BX, UK;
| | - Leila Karimi
- Department of Medical Informatics, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (L.K.); (K.M.C.V.)
| | - Maximilian Schieck
- Department of Pediatric Pneumology and Allergy, University Children’s Hospital Regensburg (KUNO), Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (M.S.); (M.K.)
- Department of Human Genetics, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Lesly-Anne Samedy-Bates
- Department of Medicine, University of California, San Francisco, CA 94143, USA; (L.-A.S.-B.); (E.G.B.)
- Department of Bioengineering and Therapeutic Sciences, University of California, 533 Parnassus Ave, San Francisco, CA 94143, USA
| | - Roger Tavendale
- Population Pharmacogenetics Group, Biomedical Research Institute, Ninewells Hospital, and Medical School, University of Dundee, Dundee DD1 9SY, UK; (R.T.); (S.M.); (C.N.P.)
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Avenida de Monforte de Lemos, 5, 28029 Madrid, Spain;
- Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrín, Calle Barranco de la Ballena s/n, 35019 Las Palmas de Gran Canaria, Spain
- Keenan Research Center for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8, Canada
| | - Somnath Mukhopadhyay
- Population Pharmacogenetics Group, Biomedical Research Institute, Ninewells Hospital, and Medical School, University of Dundee, Dundee DD1 9SY, UK; (R.T.); (S.M.); (C.N.P.)
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Royal Alexandra Children’s Hospital, 94 N-S Rd, Falmer, Brighton BN2 5BE, UK
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, 200 London Rd, Liverpool L3 9TA, UK;
| | - Katia M. C. Verhamme
- Department of Medical Informatics, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (L.K.); (K.M.C.V.)
| | - Michael Kabesch
- Department of Pediatric Pneumology and Allergy, University Children’s Hospital Regensburg (KUNO), Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (M.S.); (M.K.)
| | - Daniel B. Hawcutt
- Department of Women’s and Children’s Health, University of Liverpool, Liverpool L69 3BX, UK;
- Alder Hey Children’s Hospital, E Prescot Rd, Liverpool L14 5AB, UK
| | - Steve Turner
- Child Health, University of Aberdeen, King’s College, Aberdeen AB24 3FX, UK;
| | - Colin N. Palmer
- Population Pharmacogenetics Group, Biomedical Research Institute, Ninewells Hospital, and Medical School, University of Dundee, Dundee DD1 9SY, UK; (R.T.); (S.M.); (C.N.P.)
| | - Kelan G. Tantisira
- The Channing Division of Network Medicine, Department of Medicine, Brigham & Women’s Hospital and Harvard Medical School, 75 Francis St, Boston, MA 02115, USA; (J.L.); (K.G.T.)
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Esteban G. Burchard
- Department of Medicine, University of California, San Francisco, CA 94143, USA; (L.-A.S.-B.); (E.G.B.)
- Department of Bioengineering and Therapeutic Sciences, University of California, 533 Parnassus Ave, San Francisco, CA 94143, USA
| | - Anke H. Maitland-van der Zee
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (S.J.V.); (A.H.M.-v.d.Z.)
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Princetonplein 5, 3584 CC Utrecht, The Netherlands
- Department of Pediatric Respiratory Medicine and Allergy, Emma’s Children Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Carlos Flores
- Research Unit, Hospital Universitario N.S. de Candelaria, Universidad de La Laguna, Carretera General del Rosario 145, 38010 Santa Cruz de Tenerife, Spain;
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Avenida de Monforte de Lemos, 5, 28029 Madrid, Spain;
- Genomics Division, Instituto Tecnológico y de Energías Renovables (ITER), Polígono Industrial de Granadilla, 38600 Granadilla, Spain
- Instituto de Tecnologías Biomédicas (ITB), Universidad de La Laguna, Faculty of Health Sciences, Apartado 456, 38200 San Cristóbal de La Laguna, Spain
| | - Uroš Potočnik
- Center for Human Molecular Genetics and Pharmacogenomics, Faculty of Medicine, University of Maribor, Taborska Ulica 8, 2000 Maribor, Slovenia; (M.G.); (K.R.); (V.B.)
- Laboratory for Biochemistry, Molecular Biology, and Genomics, Faculty of Chemistry and Chemical Engineering, University of Maribor, Smetanova ulica 17, 2000 Maribor, Slovenia
- Correspondence: (N.H.-P.); (U.P.); Tel.: +46-0702983315 (N.H.-P.); +386-22345854 (U.P.)
| | - Maria Pino-Yanes
- Genomics and Health Group, Department of Biochemistry, Microbiology, Cell Biology and Genetics, Universidad de La Laguna, Avenida Astrofísico Francisco Sánchez s/n, Faculty of Science, Apartado 456, 38200 San Cristóbal de La Laguna, Spain;
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Avenida de Monforte de Lemos, 5, 28029 Madrid, Spain;
- Instituto de Tecnologías Biomédicas (ITB), Universidad de La Laguna, Faculty of Health Sciences, Apartado 456, 38200 San Cristóbal de La Laguna, Spain
| |
Collapse
|
8
|
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.
Collapse
Affiliation(s)
- James S Leung
- McMaster University, Faculty of Health Sciences, Department of Pediatrics, McMaster Children's Hospital, Hamilton, ON, Canada
| |
Collapse
|
9
|
Cheetham AL, Navanandan N, Leonard J, Spaur K, Markowitz G, Adelgais KM. Impact of prehospital pediatric asthma management protocol adherence on clinical outcomes. J Asthma 2021; 59:937-945. [PMID: 33504232 DOI: 10.1080/02770903.2021.1881969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the frequency of EMS protocol non-adherence during pediatric asthma encounters and its association with emergency department (ED) length of stay (LOS) and hospital admission. METHODS This is a retrospective review of asthma encounters aged 2-17 years transported by EMS to a pediatric ED from 2012 to 2017. Our primary outcome was hospital admission based on prehospital protocol adherence defined as: (1) bronchodilator administration, (2) treatment of hypoxia with oxygen, or (3) administration of intramuscular (IM) epinephrine in encounters with high severity of distress. Multivariable logistic regression estimated the association between protocol non-adherence and hospital admission. RESULTS During the study period, 290 EMS encounters met inclusion criteria. Median age was 9 years (IQR 5-12), 63% were male, 40% had moderate to severe exacerbations, and 24% were admitted. Protocol non-adherence occurred in 32% of encounters with failure to administer bronchodilators in 27% and failure to administer IM epinephrine when indicated in 83%. Prehospital steroids were administered in 8% of encounters. After adjusting for covariates, protocol non-adherence was not statistically associated with likelihood of inpatient admission (OR 1.3; 95% CI: 0.6-2.6). CONCLUSIONS Among prehospital pediatric asthma encounters, EMS protocol non-adherence is common but not associated with a higher frequency of hospital admission. Hospital admission was associated with acute exacerbation severity suggesting further research is needed to develop a valid prehospital asthma severity assessment scoring tool. Supplemental data for this article can be accessed at publisher's website.
Collapse
Affiliation(s)
- Alexandra L Cheetham
- Pediatric Residency Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jan Leonard
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kelsey Spaur
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Kathleen M Adelgais
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
10
|
Russi BW, Lew A, McKinley SD, Morrison JM, Sochet AA. High-flow nasal cannula and bilevel positive airway pressure for pediatric status asthmaticus: a single center, retrospective descriptive and comparative cohort study. J Asthma 2021; 59:757-764. [PMID: 33401990 DOI: 10.1080/02770903.2021.1872085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION We aimed to describe patient characteristics and clinical outcomes for children hospitalized for status asthmaticus (SA) receiving high-flow nasal cannula (HFNC) or bilevel positive airway pressure (BiPAP). METHODS We performed a single center, retrospective cohort study among 39 children admitted for SA aged 5-17 years from January 2016 to May 2019 to a quaternary pediatric intensive care unit (PICU). Cohorts were defined by BiPAP versus HFNC exposure and assessed to determine if differences existed in demographics, anthropometrics, comorbidities, asthma severity indices, historical factors, duration of noninvasive ventilation, and asthma-related clinical outcomes (i.e. length of stay, mechanical ventilation rates, exposure to concurrent sedatives/anxiolysis, and rate of adjunctive therapy exposure). RESULTS Thirty-three percent (n = 13) received HFNC (33%) and 67% (n = 26) BiPAP. Children receiving BiPAP had greater age (10.9 ± 3.7 vs. 6.8 ± 2.2 years, P < 0.01), asthma severity (proportion with severe NHLBI classification: 38% vs. 0%, P < 0.01; median pediatric asthma severity score: 13[12,14] vs. 10[9,12], P < 0.01), previous PICU admissions (62% vs. 15%, P = 0.01), frequency of prescribed anxiolysis/sedation (42% vs. 8%, P = 0.02), and median duration of continuous albuterol (1.7[1,3.1] vs. 0.9[0.7,1.6] days, P = 0.03) compared to those on HFNC. Those on HFNC more commonly were treated comorbid bacterial pneumonia (69% vs. 19%, P < 0.01). No differences in NIV duration, mortality, mechanical ventilation rates, or LOS were observed. CONCLUSIONS Our data suggest a trial of BiPAP or HFNC appears well tolerated in children with SA. Prospective trials are needed to establish modality superiority and identify patient or clinical characteristics that prompt use of HFNC over BiPAP.
Collapse
Affiliation(s)
| | - Alicia Lew
- University of South Florida, Tampa, FL, USA
| | | | - John M Morrison
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Johns Hopkins University, Baltimore, MD, USA
| | - Anthony A Sochet
- University of South Florida, Tampa, FL, USA.,Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Chacko J, King C, Harkness D, Messahel S, Grice J, Roe J, Mullen N, Sinha IP, Hawcutt DB. Pediatric acute asthma scoring systems: a systematic review and survey of UK practice. J Am Coll Emerg Physicians Open 2020; 1:1000-1008. [PMID: 33145551 PMCID: PMC7593416 DOI: 10.1002/emp2.12083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/30/2020] [Accepted: 04/08/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acute exacerbations of asthma are common in children. Multiple asthma severity scores exist, but current emergency department (ED) use of severity scores is not known. METHODS A systematic review was undertaken to identify the parameters collected in pediatric asthma severity scores. A survey of Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI) sites was undertaken to ascertain routinely collected asthma data and information about severity scores. Included studies examined severity of asthma exacerbation in children 5-18 years of age with extractable severity parameters. RESULTS Sixteen articles were eligible, containing 17 asthma severity scores. The severity scores assessed combinations of 15 different parameters (median, 6; range, 2-8). The most common parameters considered were expiratory wheeze (15/17), inspiratory wheeze (13/17), respiratory rate (10/17), and general accessory muscle use (9/17). Fifty-nine PERUKI centers responded to the questionnaire. Twenty centers (33.1%) currently assess severity, but few use a published score. The most commonly recorded routine data required for severity scores were oxygen saturations (59/59, 100%), heart rate, and respiratory rate (58/59, 98.3% for both). Among well-validated scores like the Pulmonary Index Score (PIS), Pediatric Asthma Severity Score (PASS), Childhood Asthma Score (CAS), and the Pediatric Respiratory Assessment Measure (PRAM), only 6/59 (10.2%), 3/59 (5.1%), 1/59 (1.7%), and 0 (0%) of units respectively routinely collect the data required to calculate them. CONCLUSION Standardized published pediatric asthma severity scores are infrequently used. Improved routine data collection focusing on the key parameters common to multiple scores could improve this, facilitating research and audit of pediatric acute asthma.
Collapse
Affiliation(s)
- Jerry Chacko
- School of MedicineUniversity of LiverpoolLiverpoolUK
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpoolUK
| | - Charlotte King
- Royal Liverpool and Broadgreen University Hospital TrustLiverpoolUK
| | - David Harkness
- National Institute for Health Research Alder Hey Clinical Research FacilityAlder Hey Children's HospitalLiverpoolUK
| | - Shrouk Messahel
- Emergency DepartmentAlder Hey Children's HospitalLiverpoolUK
| | - Julie Grice
- Emergency DepartmentAlder Hey Children's HospitalLiverpoolUK
| | - John Roe
- Darwin Emergency DepartmentDarwinNorthern TerritoryAustralia
| | - Niall Mullen
- Paediatric Emergency MedicineSunderland Royal HospitalSunderlandUK
| | - Ian P. Sinha
- Department of Respiratory MedicineAlder Hey Children's HospitalLiverpoolUK
| | - Daniel B. Hawcutt
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpoolUK
| | | |
Collapse
|
13
|
Nurse-driven Clinical Pathway Based on an Innovative Asthma Score Reduces Admission Time for Children. Pediatr Qual Saf 2020; 5:e344. [PMID: 32984742 PMCID: PMC7480997 DOI: 10.1097/pq9.0000000000000344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 07/09/2020] [Indexed: 11/26/2022] Open
Abstract
We recently demonstrated that an innovative asthma score independent of auscultation could accurately predict the requirement for bronchodilator nebulization compared to the physician's routine clinical judgment to administer bronchodilators. We aimed to standardize inpatient care for children with acute asthma by implementing a clinical pathway based on this innovative asthma score. Methods We designed a nurse-driven clinical pathway. This pathway included standardized respiratory assessments and a protocol for the nursing staff to administer bronchodilators without a specific order from the physician. We compared the length of stay and the number of readmissions to a historical cohort. Results Seventy-nine patients with moderate acute asthma completed the pathway. We obtained a total of 858 Childhood asthma scores in these patients, with a median of 11 scores per patient (interquartile range 8-17). Patients treated according to the nurse-driven protocol were 3.3 times more likely to be discharged earlier (hazard ratio, 3.29; 95% confidence interval, 2.33-4.66; P < 0.05), and length of stay was significantly reduced (median 28 versus 53 h) compared to the historical standard practice. On request, the attending physician assessed the patient's respiratory status 42 times (4.9% of all childhood asthma score assessments). Patient safety was not compromised, and none of the patients were removed from the pathway. In each group, we readmitted two (2.5%) patients within 1 week after discharge. Conclusion This nurse-driven clinical pathway for children with acute asthma based on an asthma score independent of auscultation findings significantly decreased length of stay without compromising patient safety.
Collapse
|
14
|
G Krishnan S, Wong HC, Ganapathy S, Ong GYK. Oximetry-detected pulsus paradoxus predicts for severity in paediatric asthma. Arch Dis Child 2020; 105:533-538. [PMID: 32094247 DOI: 10.1136/archdischild-2019-318043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 01/10/2020] [Accepted: 02/05/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate if qualitative visual detection of pulsus paradoxus (PP) on the pulse oximeter plethysmograph can predict outcomes for children with moderate to severe respiratory distress in a paediatric emergency department (ED). DESIGN Prospective cohort study. SETTING Paediatric ED of a tertiary paediatrics hospital in Singapore. PATIENTS Children managed for moderate to severe wheezing in the resuscitation bay of the ED. INTERVENTIONS Patients were assessed for the presence of PP based on visual detection of oximeter plethysmograph before and after initial inhaled bronchodilator therapy. MAIN OUTCOME MEASURES These include the need for adjunct medications such as aminophylline or magnesium sulfate, the need for supplementary ventilation and the need for admission to the high dependency unit (HDU) or intensive care unit (ICU). RESULTS There were 285 patients included in the study, of whom 78 (27.4%) had PP at ED presentation. There were 40 (14.0%) who had PP after initial management. Children who had PP after initial management had significantly relative risks (RR) of requiring adjunct medications (RR 12.5, 95% CI 4.0 to 38.6), need for supplementary ventilation (RR 5.6, 95% CI 1.2 to 26.5) and admission to the HDU/ICU (RR 5.6, 95% CI 3.0 to 10.4). CONCLUSION Qualitative detection of PP on pulse oximetry can be used as a potential point-of-care tool to help in the assessment of response to initial treatment in paediatric patients with acute moderate to severe asthma exacerbations. Future studies are needed to assess and validate its role in guiding ED management of acute paediatric asthma.
Collapse
Affiliation(s)
- Sandhya G Krishnan
- Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Hung Chew Wong
- Research Support Unit, Dean's Office, Yong Loo Lin School of Medicine, National University Health System, Faculty of Medicine, National University of Singapore, Singapore
| | | | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| |
Collapse
|
15
|
Intravenous Magnesium in Asthma Pharmacotherapy: Variability in Use in the PECARN Registry. J Pediatr 2020; 220:165-174.e2. [PMID: 32147221 DOI: 10.1016/j.jpeds.2020.01.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 01/06/2020] [Accepted: 01/29/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To examine the use, efficacy, and safety of intravenous magnesium sulfate (IVMg) in children with asthma whose emergency department (ED) management is recorded in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. STUDY DESIGN This multicenter retrospective cohort study analyzed clinical data from 7 EDs from 2012 to 2017. We described use of IVMg in children aged 2-17 years treated for acute asthma and its effect on blood pressure. We also used multivariable analysis to examine factors associated with use of IVMg and its association with return visits within 72 hours. RESULTS Across 61 854 asthma visits for children, clinicians administered IVMg in 6497 (10.5%). Median time from triage to IVMg administration was 154 minutes (IQR 84, 244). During 22 495 ED visits resulting in hospitalization after ED treatment, IVMg was administered in 5774 (25.7%) (range by site 15.9%, 50.6%). Patients were discharged home from the ED after 11.1% of IVMg administrations, and hypotension occurred after 6.8%. Variation in IVMg use was not explained by patient characteristics. Revisits did not differ between patients discharged after IVMg and those not receiving IVMg. CONCLUSIONS In PECARN Registry EDs, administration of IVMg occurs late in ED treatment, for a minority of the children likely to benefit, with variation between sites, which suggests the current clinical role for IVMg in preventing hospitalization is limited. Discharge after IVMg administration is likely safe. Further research should prospectively assess the efficacy and safety of early IVMg administration.
Collapse
|
16
|
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.
Collapse
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.
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Messinger AI, Bui N, Wagner BD, Szefler SJ, Vu T, Deterding RR. Novel pediatric-automated respiratory score using physiologic data and machine learning in asthma. Pediatr Pulmonol 2019; 54:1149-1155. [PMID: 31006993 PMCID: PMC6641986 DOI: 10.1002/ppul.24342] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/13/2019] [Accepted: 03/30/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Manual clinical scoring systems are the current standard used for acute asthma clinical care pathways. No automated system exists that assesses disease severity, time course, and treatment impact in pediatric acute severe asthma exacerbations. WORKING HYPOTHESIS machine learning applied to continuous vital sign data could provide a novel pediatric-automated asthma respiratory score (pARS) by using the manual pediatric asthma score (PAS) as the clinical care standard. METHODS Continuous vital sign monitoring data (heart rate, respiratory rate, and pulse oximetry) were merged with the health record data including a provider-determined PAS in children between 2 and 18 years of age admitted to the pediatric intensive care unit (PICU) for status asthmaticus. A cascaded artificial neural network (ANN) was applied to create an automated respiratory score and validated by two approaches. The ANN was compared with the Normal and Poisson regression models. RESULTS Out of an initial group of 186 patients, 128 patients met inclusion criteria. Merging physiologic data with clinical data yielded >37 000 data points for model training. The pARS score had good predictive accuracy, with 80% of the pARS values within ±2 points of the provider-determined PAS, especially over the mid-range of PASs (6-9). The Poisson and Normal distribution regressions yielded a smaller overall median absolute error. CONCLUSIONS The pARS reproduced the manually recorded PAS. Once validated and studied prospectively as a tool for research and for physician decision support, this methodology can be implemented in the PICU to objectively guide treatment decisions.
Collapse
Affiliation(s)
- Amanda I Messinger
- Department of Pediatrics, Colorado School of Medicine, The Breathing Institute, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | - Nam Bui
- Department of Computer Science, University of Colorado Boulder, Boulder, Colorado
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | - Stanley J Szefler
- Department of Pediatrics, Colorado School of Medicine, The Breathing Institute, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | - Tam Vu
- Department of Computer Science, University of Colorado Boulder, Boulder, Colorado
| | - Robin R Deterding
- Department of Pediatrics, Colorado School of Medicine, The Breathing Institute, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| |
Collapse
|
19
|
|
20
|
Sochet AA, Son S, Ryan KS, Roddy M, Barrie E, Wilsey M, McKinley SD, Nakagawa TA. Stress ulcer prophylaxis in children with status asthmaticus receiving systemic corticosteroids: a descriptive study assessing frequency of clinically important bleeding. J Asthma 2019; 57:858-865. [PMID: 31046509 DOI: 10.1080/02770903.2019.1614617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objective: To determine the frequency of clinically important bleeding (CIB) among children hospitalized for status asthmaticus with and without exposure to stress ulcer prophylaxis (SUP).Methods: We performed a single-center, retrospective cohort in 217 children admitted for asthma exacerbation aged 5-18 years from May 2015 to May 2017. We assessed cohorts with and without exposure to SUP to determine if differences in frequency of CIB exist. Study outcomes included frequency of CIB, gastrointestinal complications (occult bleeding, macroscopic bleeding, gastric perforation, and acquired gastritis), and SUP-related adverse events (ventilator associated pneumonia, C. difficile colitis, necrotizing enterocolitis, and acute thrombocytopenia).Results: Ninety-two (42%) children received SUP of which 82 were admitted to the pediatric intensive care unit (PICU). There were no differences in asthma severity or known risk factors for CIB in children with and without SUP in the PICU subcohort. We observed no CIB or SUP-related adverse events. Two subjects acquired gastritis in the no-SUP cohort and one additional subject experienced occult gastrointestinal bleeding with spontaneous symptom resolution.Conclusion: Children admitted for status asthmaticus with and without SUP had no observed incidence of CIB. In this specific population, we propose a prerequisite assessment for the presence of known stress ulcer related gastrointestinal bleeding risk factors prior to the blanket administration of SUP.
Collapse
Affiliation(s)
- Anthony A Sochet
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Sorany Son
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Kelsey S Ryan
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,College of Medicine, University of South Florida, Tampa, FL, USA
| | - Meghan Roddy
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Eddie Barrie
- College of Medicine, University of South Florida, Tampa, FL, USA
| | - Michael Wilsey
- Johns Hopkins All Children's Hospital, St. Petersburg, 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
| |
Collapse
|
21
|
González Martínez F, González Sánchez MI, Toledo del Castillo B, Pérez Moreno J, Medina Muñoz M, Rodríguez Jiménez C, Rodríguez Fernández R. Treatment with high-flow oxygen therapy in asthma exacerbations in a paediatric hospital ward: Experience from 2012 to 2016. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.anpede.2018.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
22
|
Provider Prediction of Disposition for Children With an Acute Exacerbation of Asthma Presenting to the Pediatric Emergency Department. Pediatr Emerg Care 2019; 35:108-111. [PMID: 30702540 DOI: 10.1097/pec.0000000000001723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the accuracy of the initial impression of emergency department providers on the disposition of children with asthma exacerbation. METHODS We conducted a prospective survey of physicians and other providers in the emergency department of a children's hospital and parents of children presenting with asthma exacerbation. The treating provider completed a survey after finishing the examination and immediately upon exiting the patient's room. Providers predicted the disposition of the child. Additionally, the providers indicated the likelihood of admission using several 10-cm visual analog scales (VASs). Physician accuracy was calculated, and logistic regression models and receiver operator characteristic curves were generated. RESULTS Complete data were available for 177 subjects. Medical doctors/nurse practitioners made correct predictions in 129 (79.6%; 95% confidence interval [CI], 73.4-85.8) of 162 encounters. Respiratory therapists were correct in 69 (67.6%; 95% CI, 58.6%-76.7%) of 102 encounters, and parents were correct in 116 (67.4%; 95% CI, 60.4%-74.4%) of 172 encounters. Logistic regression with disposition as the dependent variable revealed that provider VAS for likelihood of admission (odds ratio, 23.717; 95% CI, 9.298-60.495) was associated with admission. A receiver operator characteristic curve generated for actual disposition versus "likelihood of admission" VAS had an area under the curve of 0.856 (95% CI, 0.793-0.919). For admission, a VAS of greater than 7 was 89.9% specific, greater than 7.6 was 92.9% specific, and greater than 8.6 was 96% specific. CONCLUSIONS Emergency department providers correctly predicted disposition 80% of the time. Providers were particularly likely to correctly predict admission. A VAS score of 7 or greater is nearly 90% specific for admission, with specificity increasing at higher values.
Collapse
|
23
|
Gardiner MA, Wilkinson MH. Randomized Clinical Trial Comparing Breath-Enhanced to Conventional Nebulizers in the Treatment of Children with Acute Asthma. J Pediatr 2019; 204:245-249.e2. [PMID: 30392872 DOI: 10.1016/j.jpeds.2018.08.083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/03/2018] [Accepted: 08/31/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare the efficacy of a breath-enhanced and a conventional jet nebulizer in the treatment of children with moderate to severe acute asthma. STUDY DESIGN We enrolled subjects between 6 and 18 years of age presenting to the emergency department (ED) with acute asthma and an initial forced expiratory volume in 1 second (FEV1) <70% of predicted. We excluded patients with chronic disease, who required immediate resuscitation, or failed spirometry. Subjects were randomized to breath-enhanced or conventional jet delivery of a 5-mg albuterol treatment. Our primary outcome was change in FEV1, and secondary outcomes included change in clinical asthma scores, ED length of stay, disposition, and side effects. Student t test and multivariable linear regression were used to evaluate the primary outcome. RESULTS In total, 497 patients were assessed for eligibility with 118 enrolled and 107 subjects available for analysis of the primary outcome. Improvement in FEV1 was significantly greater with conventional jet nebulizer (mean ΔFEV1 +13.8% vs +9.1%, P = .04). This difference remained significant after adjustment for baseline differences. Subgroup analysis of 57 subjects with spirometry meeting American Thoracic Society/European Respiratory Society guidelines yielded similar results (mean ΔFEV1 +14.5% vs +8.5%, P=.03). There were no significant differences in clinical asthma scores, ED length of stay, disposition, or side effects. CONCLUSIONS Albuterol delivered via conventional jet nebulizer resulted in significantly greater improvement in FEV1 than albuterol delivered by breath-enhanced nebulizer, without significant differences in clinical measures. Conventional jet nebulizers may deliver albuterol to children with acute asthma more effectively than breath-enhanced nebulizers. TRIAL REGISTRATION ClinicalTrials.gov: NCT02566902.
Collapse
Affiliation(s)
- Mike A Gardiner
- Department of Pediatrics, University of California, San Diego, Rady Children's Hospital-San Diego, La Jolla, CA.
| | - Matthew H Wilkinson
- Department of Pediatrics, University of Texas at Austin, Dell Children's Medical Center of Central Texas, Austin, TX
| |
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
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.
Collapse
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
| |
Collapse
|
26
|
Nayani K, Naeem R, Munir O, Naseer N, Feroze A, Brown N, Mian AI. The clinical respiratory score predicts paediatric critical care disposition in children with respiratory distress presenting to the emergency department. BMC Pediatr 2018; 18:339. [PMID: 30376827 PMCID: PMC6208017 DOI: 10.1186/s12887-018-1317-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/22/2018] [Indexed: 01/03/2023] Open
Abstract
Background Respiratory distress is a common presenting complaint in children brought to the Emergency Department (ED). The Clinical Respiratory Score (CRS) has shown promise as a screen for severe illness in High Income Countries. We aimed to validate the admission CRS in children presenting to the ED of a Low-to Middle Income Country. Methods Children (1 month to 16 years) presenting with respiratory distress to the ED of the Aga Khan University Hospital, Karachi, Pakistan, between November 2015 to March 2016, were enrolled. The CRS was measured at initial presentation, prior to any management and 2 h after treatment was started. The predictive value for admission to the paediatric critical care units for a variety of cut offs for CRS at presentation were derived. Results A total of 112 children (70% male) of median age 12 months (IQR 2, 34.5 months) were enrolled. Patients with severe CRS (score 8–12) at presentation were more likely to be admitted to paediatric critical care (90% vs. 23% with mild-moderate CRS; OR: 5.7; 95% CI: 2.2–15.3, p < 0.001). The sensitivity and specificity of CRS > 3 in predicting outcome were 94% (95% CI 79.8–99.3) and 40% (95% CI 35–45), respectively, with a positive likelihood ratio of 1.6 (95% CI 1.31–1.98) and negative predictive value of 94% (95% CI 81–98). Conclusion An admission CRS of > 3 in the ED of a Low-to Middle Income Country had excellent predictive value for disease severity, and it should be considered for incorporation into ED triage protocols.
Collapse
Affiliation(s)
- Kanwal Nayani
- Department of Paediatrics and Child Health, AKU, Karachi, Pakistan
| | - Rubaba Naeem
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Owais Munir
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Naureen Naseer
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Asher Feroze
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Nick Brown
- Department of Paediatrics and Child Health, AKU, Karachi, Pakistan.,International Maternal and Child Health (IMCH), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Department of Paediatrics, Länssjukhuset Gävle-Sandviken, 801 87, Gävle, Sweden
| | - Asad I Mian
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan.
| |
Collapse
|
27
|
González Martínez F, González Sánchez MI, Toledo Del Castillo B, Pérez Moreno J, Medina Muñoz M, Rodríguez Jiménez C, Rodríguez Fernández R. [Treatment with high-flow oxygen therapy in asthma exacerbations in a paediatric hospital ward: Experience from 2012 to 2016]. An Pediatr (Barc) 2018; 90:72-78. [PMID: 30322768 DOI: 10.1016/j.anpedi.2018.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/26/2018] [Accepted: 06/28/2018] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To assess the experience with oxygen therapy with a high flow nasal cannula (HFNC) in hospital on patients with asthmatic exacerbation (AE) in a paediatric ward, and to assess the clinical outcome according with the initial oxygen flow (15lpm or <15lpm). METHODS This was a retrospective study of children aged 4 to 15 years with AE admitted to a paediatric ward in a tertiary level hospital between 2012 and 2016. Two groups of patients were compared; Group 1: patients treated with HFNC, and Group 2: patients treated with conventional oxygen therapy. A logistic regression model was constructed in order to identify predictive variables of HFNC. The clinical outcome of the patients was also compared according to the initial flow of HFNC (15lpm VS <15lpm). RESULTS The study included a total of 536 patients with AE, 40 (7.5%) of whom required HFNC. The median age was 5 (4-6) years. Heart rate (HR), respiratory rate (RR) and Pulmonary Score (PS) significantly decreased at 3-6hours after starting HFNC in Group 1. In the multivariate analysis, patients with high Pulmonary Score values and greater number of previous admissions required HFNC more frequently. Patients treated with an initial flow of 15lpm were admitted less frequently to the PICU than those with an initial flow less than 15lpm (13% vs 47%, p=.05). CONCLUSION HFNC seems to be a useful therapy for asthma exacerbation in paediatric wards. Severity of Pulmonary Score and the number of previous admissions could enable a risk group that needs HFNC to be identified.
Collapse
Affiliation(s)
- Felipe González Martínez
- Sección Pediatría Hospitalizados, Hospital Infantil, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - María Isabel González Sánchez
- Sección Pediatría Hospitalizados, Hospital Infantil, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Blanca Toledo Del Castillo
- Sección Pediatría Hospitalizados, Hospital Infantil, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Jimena Pérez Moreno
- Sección Pediatría Hospitalizados, Hospital Infantil, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - María Medina Muñoz
- Sección Pediatría Hospitalizados, Hospital Infantil, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Cristina Rodríguez Jiménez
- Sección Pediatría Hospitalizados, Hospital Infantil, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Rosa Rodríguez Fernández
- Sección Pediatría Hospitalizados, Hospital Infantil, Hospital General Universitario Gregorio Marañón, Madrid, España
| |
Collapse
|
28
|
Using Pleth Variability as a Triage Tool for Children With Obstructive Airway Disease in a Pediatric Emergency Department. Pediatr Emerg Care 2018; 34:702-705. [PMID: 27741074 DOI: 10.1097/pec.0000000000000887] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Patients with obstructive airway disease have varying degrees of pulsus paradoxus that correlate with illness severity. Pulsus paradoxus can be measured using plethysmography. We investigated whether plethysmograph (pleth) variability on admission to the pediatric emergency department (ED) could predict patient disposition. We hypothesized that patients with a larger pleth variability would have a higher likelihood of being admitted to a general pediatrics unit or the intensive care unit (ICU). METHODS We conducted a prospective single-center study of children aged 1 to 18 years who presented to a pediatric ED with a diagnosis of asthma or reactive airway disease. The pleth variability index (PVI) was calculated from their initial plethysmography tracing. Disposition from the ED was recorded as discharge, admission to the floor, or admission to the ICU. RESULTS A total of 117 patients were included in our study. Forty-eight patients were discharged home, 61 were admitted to the floor, and 8 were admitted to the ICU. The median PVI for each of these groups was 0.27 (interquartile range [IQR], 0.19-0.39) for discharges, 0.29 (IQR, 0.20-0.44) for patients admitted to the floor, and 0.56 (IQR, 0.35-0.70) for patients admitted to the ICU. A Kruskal-Wallis test demonstrated a significant difference in the PVI between each of the groups (P = 0.0087). CONCLUSIONS Our results suggest that PVI may be a useful tool in the triage of children who present to the ED with obstructive airway disease. Further studies should aim to assess the validity of PVI in predicting the response to bronchodilator therapy during the course of a patient's hospitalization.
Collapse
|
29
|
Abaya R, Delgado EM, Scarfone RJ, Reardon AM, Rodio B, Simpkins D, Mehta V, Hayes K, Zorc JJ. Improving efficiency of pediatric emergency asthma treatment by using metered dose inhaler. J Asthma 2018; 56:1079-1086. [PMID: 30207821 DOI: 10.1080/02770903.2018.1514629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: Evidence suggests using metered dose inhaler (MDI) to treat acute asthma in the Emergency Department reduces length of stay, though methods of implementation are lacking. We modified a treatment pathway to recommend use of MDI for mild-moderate asthma in a pediatric ED. Methods: A baseline review assessed discharged patients >2 years with an asthma diagnosis and non-emergent Emergency Severity Index triage assessment (3/4). Our multi-disciplinary team developed an intervention to increase MDI use instead of continuous albuterol (CA) using the following: (1) Redesign the asthma pathway and order set recommending MDI for ESI 3/4 patients. (2) Adding a conditional order for Respiratory Therapists to reassess and repeat MDI until patient reached mild assessment. The primary outcome was the percentage discharged within 3 hours, with a goal of a 10% increase compared to pre-intervention. Balancing measures included admission and revisit rates. Results: 7635 patients met eligibility before pathway change; 12,673 were seen in the subsequent 18 months. For target patients, the percentage discharged in <3 hours increased from 39% to 49%; reduction in median length of stay was 33 minutes. We identified special cause variation for reduction in CA use from 43% to 25%; Revisit rate and length of stay for higher-acuity patients did not change; overall asthma admissions decreased by 8%. Changes were sustained for 18 months. Conclusion: A change to an ED asthma pathway recommending MDI for mild-moderate asthma led to a rapid and sustained decrease in continuous albuterol use, length of stay, and admission rate.
Collapse
Affiliation(s)
- Ruth Abaya
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Eva M Delgado
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Richard J Scarfone
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ann Marie Reardon
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bonnie Rodio
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Denise Simpkins
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vaidehi Mehta
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Katie Hayes
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph J Zorc
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
30
|
Uong A, Brandwein A, Crilly C, York T, Avarello J, Gangadharan S. Pleth Variability Index to Assess Course of Illness in Children with Asthma. J Emerg Med 2018; 55:179-184. [PMID: 30056835 DOI: 10.1016/j.jemermed.2018.04.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 03/02/2018] [Accepted: 04/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Status asthmaticus (SA) is a common reason for admission to the pediatric emergency department (ED). Assessing asthma severity efficiently in the ED can be challenging for clinicians. Adjunctive tools for the clinician have demonstrated inconsistent results. Studies have shown that pulsus paradoxus (PP) correlates with asthma severity. Pleth Variability Index (PVI) is a surrogate measure of PP. OBJECTIVE We investigated whether PVI at triage correlates with disposition from the ED. METHODS We recruited children aged 2-18 years old who presented to the pediatric ED of a tertiary care children's hospital with SA. PVI, Respiratory Severity Score, and vital signs were documented at triage and 2 hours into each patient's ED stay. PVI was measured using the Masimo Radical-7® monitor (Masimo Corp., Irvine, CA). RESULTS Thirty-eight patients were recruited. Twenty-seven patients were discharged home, 10 patients were admitted to the general pediatrics floor and 1 patient was admitted to the intensive care unit. PVI values at triage did not correlate with disposition from the ED (p = 0.63). Additionally, when trending the change in PVI after 2 hours of therapy in the ED, no statistically significant patterns were demonstrated. CONCLUSIONS Our study did not demonstrate a correlation between PVI and clinical course for asthmatics. PVI may be more clinically relevant in sicker children. Furthermore, it is possible that continuous monitoring of PVI may demonstrate more unique trends in relation to asthma severity versus single values of PVI. Additional studies are necessary to help clarify the relationship between PVI and the clinical course of children with SA.
Collapse
Affiliation(s)
- Audrey Uong
- Division of Pediatric Hospital Medicine, Children's Hospital at Montefiore/Albert Einstein School of Medicine, Bronx, New York
| | - Ariel Brandwein
- Division of Critical Care, Cohen Children's Medical Center, New Hyde Park, New York
| | - Colin Crilly
- Division of Emergency Care Medicine, Cohen Children's Medical Center, New Hyde Park, New York
| | - Tamar York
- Division of Emergency Care Medicine, Cohen Children's Medical Center, New Hyde Park, New York
| | - Jahn Avarello
- Division of Emergency Care Medicine, Cohen Children's Medical Center, New Hyde Park, New York
| | - Sandeep Gangadharan
- Division of Critical Care Medicine, Children's Hospital at Montefiore/Albert Einstein School of Medicine, Bronx, New York
| |
Collapse
|
31
|
DeSanti RL, Agasthya N, Hunter K, Hussain MJ. The effectiveness of magnesium sulfate for status asthmaticus outside the intensive care setting. Pediatr Pulmonol 2018; 53:866-871. [PMID: 29660840 DOI: 10.1002/ppul.24013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 03/21/2018] [Indexed: 11/07/2022]
Abstract
AIM Magnesium is an adjunctive therapy used in patients with status asthmaticus who do not respond to conventional therapy. The optimal time from initiation of therapy, to determination of response and administration of magnesium has not yet been resolved. Our objective was to determine if magnesium administered in the non-intensive care setting can decrease duration of continuous albuterol and hospital length of stay. METHODS We performed a retrospective cohort analysis of children ages 2-18 years admitted to the pediatric unit on continuous albuterol between January 2014 and December 2015 in a tertiary care children's hospital. Cohorts were matched on respiratory assessment score (RAS) obtained at a similar duration of albuterol therapy and evaluated for the total duration of continuous albuterol, length of stay (LOS), and adverse events. RESULTS Thirty-three patients who received magnesium were matched to 33 patients with the same RAS at a similar duration of continuous albuterol therapy who did not receive magnesium. Those who received magnesium had longer duration on continuous albuterol (34 vs 18 h; P = 0.001; 95% confidence interval [CI] 4-20; effect size 0.41) and longer LOS (72 vs 49 h; P = 0.037; 95% confidence interval [CI] 1-33; effect size 0.26) than those who did not receive magnesium. CONCLUSION Children requiring continuous albuterol for status asthmaticus can be administered magnesium sulfate outside the PICU with a low incidence of adverse events; however, among a RAS matched cohort, those who received magnesium did not experience shorter time on continuous albuterol, or hospital length of stay.
Collapse
Affiliation(s)
- Ryan L DeSanti
- Department of Pediatric Critical Care, University of Wisconsin, Madison, Wisconsin
| | - Nisha Agasthya
- Department of Pediatric Critical Care, Nemours/Alfred I DuPont Hospital for Children, Wilmington, Delaware
| | - Krystal Hunter
- Cooper Research Institute, Cooper University Hospital, Camden, New Jersey.,Cooper Medical School of Rowan University, Camden, New Jersey
| | - Mohammed J Hussain
- Cooper Medical School of Rowan University, Camden, New Jersey.,Department of Pediatrics, Cooper University Hospital, Camden, New Jersey.,Weisman Children's Rehabilitation Hospital, Marlton, New Jersey
| |
Collapse
|
32
|
Savage TJ, Kuypers J, Chu HY, Bradford MC, Buccat AM, Qin X, Klein EJ, Jerome KR, Englund JA, Waghmare A. Enterovirus D-68 in children presenting for acute care in the hospital setting. Influenza Other Respir Viruses 2018; 12:522-528. [PMID: 29498483 PMCID: PMC6005627 DOI: 10.1111/irv.12551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Severe respiratory disease associated with enterovirus D68 (EV-D68) has been reported in hospitalized pediatric patients. Virologic and clinical characteristics of EV-D68 infections exclusively in patients presenting to a hospital Emergency Department (ED) or urgent care have not been well defined. METHODS Mid-nasal swabs from pediatric patients with respiratory symptoms presenting to the ED or urgent care were evaluated using a commercial multiplex PCR platform. Specimens positive for rhinovirus/enterovirus (HRV/EV) were subsequently tested using real-time reverse-transcriptase PCR for EV-D68. The PCR cycle threshold (CT) was used as a viral load proxy. Clinical outcomes were compared between patients with EV-D68 and patients without EV-D68 who tested positive for HRV/EV. RESULTS From August to December 2014, 511 swabs from patients with HRV/EV were available. EV-D68 was detected in 170 (33%) HRV/EV-positive samples. In multivariable models adjusted for age and underlying asthma, patients with EV-D68 were more likely to require hospitalization for respiratory reasons (odds ratio (OR): 3.11, CI: 1.85-5.25), require respiratory support (OR: 1.69, CI: 1.09-2.62), have confirmed/probable lower respiratory tract infection (LRTI; OR: 3.78, CI: 2.03-7.04), and require continuous albuterol or steroids (OR: 3.91, CI: 2.22-6.88 and OR: 4.73, CI: 2.65-8.46, respectively). Higher EV-D68 viral load was associated with need for respiratory support and LRTI in multivariate models. CONCLUSIONS Among pediatric patients presenting to the ED or urgent care, EV-D68 causes more severe disease than non-EV-D68 HRV/EV independent of underlying asthma. High viral load was associated with worse clinical outcomes. Rapid and quantitative viral testing may help identify and risk stratify patients.
Collapse
Affiliation(s)
- Timothy J. Savage
- Seattle Children's HospitalSeattleWAUSA
- University of WashingtonSeattleWAUSA
| | | | | | | | | | - Xuan Qin
- Seattle Children's HospitalSeattleWAUSA
| | - Eileen J. Klein
- Seattle Children's HospitalSeattleWAUSA
- University of WashingtonSeattleWAUSA
- Seattle Children's Research InstituteSeattleWAUSA
| | - Keith R. Jerome
- University of WashingtonSeattleWAUSA
- Fred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Janet A. Englund
- Seattle Children's HospitalSeattleWAUSA
- University of WashingtonSeattleWAUSA
- Seattle Children's Research InstituteSeattleWAUSA
| | - Alpana Waghmare
- Seattle Children's HospitalSeattleWAUSA
- University of WashingtonSeattleWAUSA
- Seattle Children's Research InstituteSeattleWAUSA
- Fred Hutchinson Cancer Research CenterSeattleWAUSA
| |
Collapse
|
33
|
Simmons JM, Biagini Myers JM, Martin LJ, Kercsmar CM, Schuler CL, Pilipenko VV, Kroner JW, He H, Austin SR, Nguyen HT, Ross KR, McCoy KS, Alter SJ, Gunkelman SM, Vauthy PA, Khurana Hershey GK. Ohio Pediatric Asthma Repository: Opportunities to Revise Care Practices to Decrease Time to Physiologic Readiness for Discharge. Hosp Pediatr 2018; 8:305-313. [PMID: 29764909 DOI: 10.1542/hpeds.2017-0085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Large-scale, multisite studies in which researchers evaluate patient- and systems-level factors associated with pediatric asthma exacerbation outcomes are lacking. We sought to investigate patient-level risks and system-level practices related to physiologic readiness for discharge (PRD) in the prospective Ohio Pediatric Asthma Repository. METHODS Participants were children ages 2 to 17 years admitted to an Ohio Pediatric Asthma Repository hospital for asthma exacerbation. Demographics, disease characteristics, and individual hospital practices were collected. The primary outcome was PRD timing (hours from admission or emergency department [ED] presentation until the first 4-hour albuterol spacing). RESULTS Data for 1005 participants were available (865 ED presentations). Several nonstandard care practices were associated with time to PRD (P < .001). Continuous pulse oximetry was associated with increased time to PRD (P = .004). ED dexamethasone administration was associated with decreased time to PRD (P < .001) and less ICU admittance and intravenous steroid use (P < .0001). Earlier receipt of chest radiograph, antibiotics, and intravenous steroids was associated with shorter time to PRD (P < .05). Care practices associated with shorter time to PRD varied markedly by hospital. CONCLUSIONS Substantial variation in care practices for inpatient asthma treatment exists among children's hospital systems in Ohio. We found several modifiable, system-level factors and therapies that contribute to PRD that warrant further investigation to identify the best and safest care practices. We also found that there was no standardized measure of exacerbation severity used across the hospitals. The development of such a tool is a critical gap in current practice and is needed to enable definitive comparative effectiveness studies of the management of acute asthma exacerbation.
Collapse
Affiliation(s)
- Jeffrey M Simmons
- Divisions of Hospital Medicine.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jocelyn M Biagini Myers
- Asthma Research.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lisa J Martin
- Human Genetics, and.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Carolyn M Kercsmar
- Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christine L Schuler
- Divisions of Hospital Medicine.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | | | | | | | | | - Kristie R Ross
- Department of Pediatrics-Pulmonary, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Karen S McCoy
- Division of Pediatric Pulmonology, Nationwide Children's Hospital, Columbus, Ohio
| | - Sherman J Alter
- Department of Infectious Disease, Dayton Children's Hospital, Dayton, Ohio
| | | | - Pierre A Vauthy
- Department of Pediatric Pulmonary Medicine, ProMedica Toledo Children's Hospital, Toledo, Ohio; and
| | - Gurjit K Khurana Hershey
- Asthma Research, .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
34
|
Craig S, Graudins A, Dalziel SR, Powell CVE, Babl FE. Review article: A primer for clinical researchers in the emergency department: Part VI. Measuring what matters: Core outcome sets in emergency medicine research. Emerg Med Australas 2018; 31:29-34. [DOI: 10.1111/1742-6723.12970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 02/18/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Simon Craig
- Department of Medicine; Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University; Melbourne Victoria Australia
- Paediatric Emergency Department; Monash Medical Centre; Melbourne Victoria Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT); Melbourne, Victoria Australia
- Emergency Research; Murdoch Children's Research Institute; Melbourne Victoria Australia
| | - Andis Graudins
- Department of Medicine; Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University; Melbourne Victoria Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT); Melbourne, Victoria Australia
- Monash Emergency Service; Monash Health, Dandenong Hospital; Melbourne Victoria Australia
| | - Stuart R Dalziel
- Paediatric Research in Emergency Departments International Collaborative (PREDICT); Melbourne, Victoria Australia
- Children's Emergency Department; Starship Children's Hospital; Auckland New Zealand
- Liggins Institute; The University of Auckland; Auckland New Zealand
| | - Colin VE Powell
- Department of Child Health; Division of Population Medicine, School of Medicine, Cardiff University; Cardiff UK
- Department of Emergency Medicine, SIDRA Medical and Research Centre; Doha Qatar
| | - Franz E Babl
- Paediatric Research in Emergency Departments International Collaborative (PREDICT); Melbourne, Victoria Australia
- Emergency Research; Murdoch Children's Research Institute; Melbourne Victoria Australia
- Emergency Department; Royal Children's Hospital; Melbourne Victoria Australia
- The University of Melbourne; Melbourne, Victoria Australia
| |
Collapse
|
35
|
Improving Prehospital Management of Children With Respiratory Distress. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
36
|
What Is the Role for Magnesium to Treat Severe Pediatric Asthma Exacerbations? CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
37
|
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]
|
38
|
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.
Collapse
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
| |
Collapse
|
39
|
Maekawa T, Ohya Y, Mikami M, Uematsu S, Ishiguro A. Clinical Utility of the Modified Pulmonary Index Score as an Objective Assessment Tool for Acute Asthma Exacerbation in Children. JMA J 2018; 1:57-66. [PMID: 33748523 PMCID: PMC7969834 DOI: 10.31662/jmaj.2018-0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/27/2018] [Indexed: 12/22/2022] Open
Abstract
Introduction: The Modified Pulmonary Index Score (MPIS) was developed as an objective assessment tool for acute asthma exacerbation in children. Although it is considered reliable, there are no known studies of its clinical utility. The objective of this study was to evaluate the validity of the MPIS for children with acute asthma in a clinical setting. Methods: In this retrospective study conducted between July 2009 and June 2011 using electronic medical records at the emergency department of a single pediatric medical center in Tokyo, Japan, the MPIS was recorded for patients with acute asthma at initial assessment and after treatment with an inhaled beta-agonist. We evaluated the responsiveness and predictive validity of the MPIS using disposition as an outcome. Results: A total of 2242 patients were assessed using the MPIS (median age, 3 years; 71.2% patients were 5 years or younger). The mean (SD) MPIS at initial assessment was 7.1 (3.6) and was significantly higher for the admission group than for the non-admission group (9.9 [2.9] vs. 5.9 [3.1]; P < 0.001). The receiver operator characteristic curve of the initial MPIS for hospital admission demonstrated moderate predictive ability (area under the curve, 0.83). An MPIS reduction of 3 or more indicated a clinically significant change when the MPIS at initial assessment was between 6 and 10 (risk ratio for admission [95% CI], 0.41 [0.28–0.60]; P < 0.001). Conclusion: The MPIS demonstrated good concurrent validity, predictive validity, and responsiveness in a wide range of clinical settings.
Collapse
Affiliation(s)
- Takanobu Maekawa
- Division of Pediatrics, Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yukihiro Ohya
- Division of Allergy, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Masashi Mikami
- Division of Biostatistics, Center for Clinical Research, National Center for Child Health and Development, Tokyo, Japan
| | - Satoko Uematsu
- Division of Emergency Service and Transport Medicine, Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Akira Ishiguro
- Department of Postgraduate Education and Training, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
40
|
Pade KH, Seik-Ismail ST, Chang TP, Wang VJ. Utilization of just-in-time training for nursing education using the LA Phonospirometry asthma tool. J Asthma 2017; 55:811-815. [PMID: 28846445 DOI: 10.1080/02770903.2017.1366507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Just-in-time training (JITT) has been used to teach and re-teach known medical techniques, but has not been used to teach novel techniques. We aimed to assess the performance retention of JITT on a novel asthma exacerbation severity assessment technique known as Los Angeles (LA) Phonospirometry. METHODS This was a prospective cohort study using a convenience sample of pediatric emergency department registered nurses (RNs) who were asked to watch a brief instructional digital video on LA Phonospirometry, and then asked to practice the technique on a research assistant (RA). A checklist was used to evaluate proficiency with the primary outcome being the number correct on the checklist. The secondary outcome included whether or not they could identify a common error demonstrated by the RA. RNs were re-tested after 4-6 months to assess skill retention. RESULTS Forty RNs were enrolled in the study and six were lost to follow-up. The mean time from the first to second testing was 5.4 months ± 0.5 months. The mean score of the first part of the checklist on the initial testing was 4.6 ± 0.7 and on second testing was 3.8 ± 1.5 (p = 0.008). This represented a drop in scores and thus minimal knowledge decay of 18% (from 91% to 73%). The mean values for number of errors picked up for the first test and second test were 1.3 and 1.5, respectively (p = 0.2). CONCLUSIONS JITT demonstrated feasibility as a rapid instructional tool for RNs, with a limited decay in cognitive knowledge surrounding the LA Phonospirometry technique.
Collapse
Affiliation(s)
- Kathryn H Pade
- a Department of Emergency Medicine and Transport , Children's Hospital Los Angeles , Los Angeles , CA , USA
| | - Sophia T Seik-Ismail
- a Department of Emergency Medicine and Transport , Children's Hospital Los Angeles , Los Angeles , CA , USA
| | - Todd P Chang
- a Department of Emergency Medicine and Transport , Children's Hospital Los Angeles , Los Angeles , CA , USA
| | - Vincent J Wang
- a Department of Emergency Medicine and Transport , Children's Hospital Los Angeles , Los Angeles , CA , USA
| |
Collapse
|
41
|
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.
Collapse
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
| |
Collapse
|
42
|
Positive Expiratory Pressure for the Treatment of Acute Asthma Exacerbations: A Randomized Controlled Trial. J Pediatr 2017; 185:149-154.e2. [PMID: 28284473 DOI: 10.1016/j.jpeds.2017.02.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 01/30/2017] [Accepted: 02/09/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate the efficacy of brief, single administration of positive expiratory pressure (PEP) therapy in reducing clinical severity and need for additional second-line therapies and hospitalization in children presenting to the emergency department (ED) with acute asthma. STUDY DESIGN This was a prospective randomized controlled trial of children 2-18 years of age presenting to a tertiary-care academic pediatric ED with moderate-to-severe asthma exacerbations from December 2014 to June 2016. Children who continued to have moderate asthma severity after completion of initial therapies (albuterol/ipratropium bromide and corticosteroids) were randomized to receive PEP therapy or standard of care. The primary outcome was change in pulmonary asthma score before and after intervention, as assessed by a blinded physician. Secondary outcomes included need for additional therapies, ED length of stay, and disposition. RESULTS A total of 52 patients were randomized to receive either PEP (n?=?26) or standard therapy (n?=?26). Study groups were similar in demographics and baseline characteristics. There was no significant difference in primary outcome between groups with a mean change in Pulmonary Asthma Score of 0.92 (±1.2) in the PEP group and 0.40 (±1.2) in the standard group (P?=?.12). There also was no significant difference in need for additional therapies, ED length of stay, and disposition. Mild, self-resolving side effects were observed in 3 subjects receiving PEP therapy. CONCLUSION Single, brief, administration of PEP therapy after completion of first-line therapies does not improve clinical severity in children presenting to the ED with acute asthma. TRIAL REGISTRATION ClinicalTrials.gov: NCT02494076.
Collapse
|
43
|
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.
Collapse
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
| |
Collapse
|
44
|
Liu X, Yu T, Rower JE, Campbell SC, Sherwin CMT, Johnson MD. Optimizing the use of intravenous magnesium sulfate for acute asthma treatment in children. Pediatr Pulmonol 2016; 51:1414-1421. [PMID: 27218606 DOI: 10.1002/ppul.23482] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 04/29/2016] [Accepted: 05/06/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Asthma is the most common pediatric chronic disease and currently affects 7.1 million children in the United States. Many children experience acute asthma exacerbations. Many children also require hospitalization despite treatment in an emergency department with current standard therapy (corticosteroids, albuterol, and ipratropium). These hospitalizations may be avoided if effective adjunctive therapies can be developed to adequately treat severe exacerbations. METHODS Publications were searched in the PubMed database using the following keywords: magnesium AND asthma AND children AND randomized controlled trial. A total of 30 publications were returned. References of relevant articles were also screened. We included publications of controlled randomized trials where intravenous magnesium sulfate was studied in children (age < 18 years) with acute asthma (n = 7). We excluded studies in adults or trials with other formulations of magnesium (e.g., nebulized). RESULTS Previous studies have demonstrated that intravenous magnesium sulfate (IV MgSO4 ) significantly improves respiratory function and reduces hospitalization rate in children with moderate to severe asthma exacerbations. Current dosing regimens involve a short infusion of 25-75 mg/kg over 20 min (maximum 2-2.5 g/dose), though no studies have directly compared dosages for relative efficacy. Several studies suggest utilizing a peak plasma concentration of magnesium higher than 4 mg/dL as a surrogate of efficacy. This review summarizes the literature regarding the use of IV MgSO4 for the treatment of pediatric acute asthma. CONCLUSIONS We suggest that optimized dosing regimens could be developed using a linked pharmacokinetic-pharmacodynamic modeling and simulation approach. We propose the factors that should be considered in future clinical trial design in order to better understand the use of IV MgSO4 in pediatric acute asthma. Pediatr Pulmonol. 2016;51:1414-1421. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Xiaoxi Liu
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, Utah, 84108
| | - Tian Yu
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, Utah, 84108
| | - Joseph E Rower
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, Utah, 84108
| | - Sarah C Campbell
- Nelson Laboratories, Inc, Salt Lake City, Utah.,Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah
| | - Catherine M T Sherwin
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, Utah, 84108.,Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah.,Department of Pediatrics, Clinical Trials Office, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael D Johnson
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah.,Department of Emergency, Rapid Treatment Unit, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah
| |
Collapse
|
45
|
Arnold DH, Sills MR, Walsh CG. The asthma prediction rule to decrease hospitalizations for children with asthma. Curr Opin Allergy Clin Immunol 2016; 16:201-9. [PMID: 26918532 PMCID: PMC5380119 DOI: 10.1097/aci.0000000000000259] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The aim of the present review was to discuss the challenges around clinical decision-making for hospitalization of children with acute asthma exacerbations and the development, internal validation, and future potential of the asthma prediction rule (APR) to provide meaningful clinical decision-support that might decrease unnecessary hospitalizations. RECENT FINDINGS The APR was developed and internally validated using predictor variables available before treatment in the emergency department, and performed well to predict 'need-for-hospitalization.' Oxygen saturation on room air and expiratory phase prolongation were most strongly associated with need-for-hospitalization. SUMMARY Research on prediction rules in pediatric asthma is rare. We developed and internally validated the APR using clinically intuitive predictor variables that are available at the bedside. Before incorporation into electronic decision-support the APR must undergo external validation and an impact analysis to determine if use of this tool will change clinician behavior and improve patient outcomes.
Collapse
Affiliation(s)
- Donald H Arnold
- aDivision of Emergency Medicine, Department of Pediatrics and Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee bSection of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado cDepartment of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | | |
Collapse
|
46
|
Abstract
Respiratory emergencies are 1 of the most common reasons parents seek evaluation for the their children in the emergency department (ED) each year, and respiratory failure is the most common cause of cardiopulmonary arrest in pediatric patients. Whereas many respiratory illnesses are mild and self-limiting, others are life threatening and require prompt diagnosis and management. Therefore, it is imperative that emergency clinicians be able to promptly recognize and manage these illnesses. This article reviews ED diagnosis and management of foreign body aspiration, asthma exacerbation, epiglottitis, bronchiolitis, community-acquired pneumonia, and pertussis.
Collapse
|
47
|
Arnold DH, O'Connor MG, Hartert TV. Acute Asthma Intensity Research Score: updated performance characteristics for prediction of hospitalization and lung function. Ann Allergy Asthma Immunol 2015; 115:69-70. [PMID: 25890449 DOI: 10.1016/j.anai.2015.03.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/22/2015] [Accepted: 03/24/2015] [Indexed: 12/26/2022]
Affiliation(s)
- Donald H Arnold
- Department of Pediatrics, Division of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - Michael G O'Connor
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Tina V Hartert
- Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| |
Collapse
|
48
|
Arnold DH, Gebretsadik T, Moons KGM, Harrell FE, Hartert TV. Development and internal validation of a pediatric acute asthma prediction rule for hospitalization. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2015; 3:228-35. [PMID: 25609324 PMCID: PMC4355052 DOI: 10.1016/j.jaip.2014.09.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 09/18/2014] [Accepted: 09/18/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Clinicians have difficulty predicting need for hospitalization of children with acute asthma exacerbations. OBJECTIVE The objective of this study was to develop and internally validate a multivariable asthma prediction rule (APR) to inform hospitalization decision making in children aged 5-17 years with acute asthma exacerbations. METHODS Between April 2008 and February 2013 we enrolled a prospective cohort of patients aged 5-17 years with asthma who presented to our pediatric emergency department with acute exacerbations. Predictors for APR modeling included 15 demographic characteristics, asthma chronic control measures, and pulmonary examination findings in participants at the time of triage and before treatment. The primary outcome variable for APR modeling was need for hospitalization (length of stay >24 h for those admitted to hospital or relapse for those discharged). A secondary outcome was the hospitalization decision of the clinical team. We used penalized maximum likelihood multiple logistic regression modeling to examine the adjusted association of each predictor variable with the outcome. Backward step-down variable selection techniques were used to yield reduced-form models. RESULTS Data from 928 of 933 participants were used for prediction rule modeling, with median [interquartile range] age 8.8 [6.9, 11.2] years, 61% male, and 59% African-American race. Both full (penalized) and reduced-form models for each outcome calibrated well, with bootstrap-corrected c-indices of 0.74 and 0.73 for need for hospitalization and 0.81 in each case for hospitalization decision. CONCLUSION The APR predicts the need for hospitalization of children with acute asthma exacerbations using predictor variables available at the time of presentation to an emergency department.
Collapse
Affiliation(s)
- Donald H Arnold
- Departments of Pediatrics and Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tenn; Center for Asthma & Environmental Sciences Research, Vanderbilt University School of Medicine, Nashville, Tenn.
| | - Tebeb Gebretsadik
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tenn; Center for Asthma & Environmental Sciences Research, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Karel G M Moons
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tenn; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Tina V Hartert
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn; Center for Asthma & Environmental Sciences Research, Vanderbilt University School of Medicine, Nashville, Tenn
| |
Collapse
|
49
|
Maekawa T, Oba MS, Katsunuma T, Ishiguro A, Ohya Y, Nakamura H. Modified pulmonary index score was sufficiently reliable to assess the severity of acute asthma exacerbations in children. Allergol Int 2014; 63:603-7. [PMID: 25249062 DOI: 10.2332/allergolint.13-oa-0681] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Accepted: 05/25/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The Modified Pulmonary Index Score (MPIS) was developed as an indicator of the severity of acute asthma in children. The objective of this study is to evaluate the reliability and validity of the MPIS for children with acute asthma, including those five years or younger in age. METHODS We evaluated the inter-rater reliability and internal consistency of the MPIS by having at least two trained physicians and a nurse-each of whom was blinded to the others' scores-simultaneously examine inpatients with asthma exacerbation and rate them according to the MPIS. We also evaluated the intraclass correlation coefficient (ICC), kappa, Cronbach's α and correlations between the MPIS and other indicators associated with asthma severity. RESULTS A total of 25 children (median age, five years; 13 patients were five years or younger in age) were enrolled in this study. The MPIS showed excellent inter-rater reliability (all ages: ICC = 0.95, 95% CI = 0.94-0.97; five years or younger: ICC = 0.93, 95% CI = 0.89-0.96) and good internal consistency (all ages: Cronbach's α = 0.87; five years or younger: Cronbach's α = 0.85). The MPIS showed good correlation with a visual analogue scale assessed by the physicians. CONCLUSIONS The MPIS was a sufficiently reliable assessment tool for children with acute asthma, including those five years or younger in age.
Collapse
Affiliation(s)
- Takanobu Maekawa
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Mari S Oba
- Department of Biostatistics and Epidemiology, Graduate School of Medicine, Yokohama City University, Kanagawa, Japan
| | - Toshio Katsunuma
- Department of Pediatrics, Jikei University Daisan Hospital, Tokyo, Japan
| | - Akira Ishiguro
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yukihiro Ohya
- Division of Allergy, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Hidefumi Nakamura
- Division for Clinical Trials, Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
50
|
The improvement in asthma severity and pulmonary functions after laser acupuncture application in asthmatic children. ACTA ACUST UNITED AC 2014. [DOI: 10.1097/01.mjx.0000457178.59145.b5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|