Management of acute, severe asthma in children

Physician and parent barriers to the use of oral corticosteroids for the prevention of paediatric URTI-induced acute asthma exacerbations at home

Objectives

Administration of oral corticosteroids at the onset of an upper respiratory tract infection (URTI) can be effective in the management of acute asthma exacerbations in children. This study was designed to identify barriers to parent-initiated implementation of clinical practice guideline-recommended use of oral corticosteroids for prophylaxis against severe asthma exacerbations in children.

Methods

Twenty-seven children who presented to BC Children's Hospital with URTI-induced asthma exacerbations were recruited. Parents received a filled prescription for a course of oral corticosteroids to be used at the earliest onset of their child's next URTI. Each family was contacted monthly over a 1-year period to inquire about URTI events, asthma symptoms, medication use and health care utilization. Focus groups were held with family physicians, paediatricians and parents; transcripts were analyzed qualitatively to identify key themes.

Results

Incidence of URTI events among participants was high (85%). Uptake of study medication was low; 44% used the medication as directed at their first URTI event. Eleven per cent of the patients who used the study medication also visited the emergency department for an exacerbation. Focus groups identified four main barriers to the effective use of parent-initiated oral corticosteroids: physician resistance and conflicting messages from providers; parent uncertainty about oral corticosteroids; multiple caregivers and relative ease of access to an emergency department.

Conclusion

We have identified key barriers to the effective use of parent-administered oral corticosteroids as an asthma management strategy and gained important insights regarding the research that is required to enhance the applicability of the strategy.

Patient- and parent-initiated oral steroids for asthma exacerbations

BACKGROUND

Asthma is a chronic inflammatory disease of the airways affecting an estimated 334 million people worldwide. During severe exacerbations, patients may need to attend a medical centre or hospital emergency department for treatment with systemic corticosteroids, which can be administered intravenously or orally. Some people with asthma are prescribed oral corticosteroids (OCS) for self-administration (i.e. patient-initiated) or to administer to their child with asthma (i.e. parent-initiated), in the event of an exacerbation. This approach to treatment is becoming increasingly common.

OBJECTIVES

To evaluate the effectiveness and safety of patient- or parent-initiated oral steroids for adults and children with asthma exacerbations.

SEARCH METHODS

We identified trials from Cochrane Airways' Specialised Register (CASR) and also conducted a search of the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch). We searched CASR from its inception to 18 May 2016 and trial registries from their inception to 24 August 2016; we imposed no restriction on language of publication.

SELECTION CRITERIA

We looked for randomised controlled trials (RCTs), reported as full-text, those published as abstract only, and unpublished data; we excluded cross-over trials.We looked for studies where adults (aged 18 years or older) or children of school age (aged 5 years or older) with asthma were randomised to receive: (a) any patient-/parent-initiated OCS or (b) placebo, normal care, alternative active treatment, or an identical personalised asthma action plan without the patient- or parent-initiated OCS component.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results to identify any studies that met the prespecified inclusion criteria.The prespecified primary outcomes were hospital admissions for asthma, asthma symptoms at follow-up and serious adverse events.

MAIN RESULTS

Despite comprehensive searches of electronic databases and clinical trial registries, we did not identify any studies meeting the inclusion criteria for this review. Five potentially relevant studies were excluded for two reasons: the intervention did not meet the inclusion criteria for this review (three studies) and studies had a cross-over design (two studies). Two of the excluded studies asked the relevant clinical question. However, these studies were excluded due to their cross-over design, as per the protocol. We contacted the authors of the cross-over trials who were unable to provide data for the first treatment period (i.e. prior to cross-over).

AUTHORS' CONCLUSIONS

There is currently no evidence from randomised trials (non-cross-over design) to inform the use of patient- or parent-initiated oral corticosteroids in people with asthma.

Safety and effectiveness of continuous aerosolized albuterol in the non-intensive care setting

OBJECTIVE

To describe the design features, utilization, and outcomes of a protocol treating children with status asthmaticus with continuous albuterol in the inpatient setting.

METHODS

We performed a retrospective cohort analysis of children ages 2 to 18 treated in the non-intensive care, inpatient setting on a standardized treatment protocol for status asthmaticus from July 2011 to June 2013. We assessed characteristics associated with continuous albuterol therapy and, for those treated, duration of therapy and the proportion who clinically deteriorated (ICU transfer or progression to enhanced respiratory support) or who were identified as having hypokalemia or an arrhythmia. Using multivariable logistic regression, we determined which factors were associated with clinical deterioration or prolonged (>24 hours) continuous albuterol.

RESULTS

Of 3003 children meeting study criteria, 1298 (43%) received continuous albuterol. Older age, black race, lower initial oxygen saturation, and higher initial age-standardized heart rate and respiratory rate were associated with initiation of continuous albuterol therapy (P < .001 for all). Median duration of therapy was 14.4 hours (interquartile range, 7.7, 24.6); 340 children (26%) experienced prolonged therapy. Seventy children (5%) experienced clinical deterioration, and 33 children (3%) had identified hypokalemia or arrhythmia. Comorbid pneumonia and emergency department administration of intravenous magnesium or subcutaneous terbutaline were associated with prolonged therapy and clinical deterioration.

CONCLUSIONS

With appropriate support structures and care processes, continuous albuterol can be delivered effectively in the non-ICU, inpatient setting with low rates of adverse outcomes. Certain initial clinical characteristics may help identify patients needing more intensive therapy.

The role of parent-initiated oral corticosteroids in preschool wheeze and school-aged asthma

PURPOSE OF REVIEW

To review the theoretical background and current evidence regarding parent-initiated oral corticosteroid (PIOCS) therapy in preschool wheeze and asthma in school-aged children.

RECENT FINDINGS

In school-aged children with asthma PIOCS, given during acute episodes, has been associated with a modest reduction in asthma symptoms and health resource utilisation. In preschool wheeze, OCS (including PIOCS) therapy appears to be ineffective.

SUMMARY

PIOCS is associated with modest benefits among school-aged children with acute asthma but is not effective among children with preschool wheeze. In older children with asthma, the potential benefits of PIOCS must be balanced against potential adverse effects associated with increased OCS administration.

Parent initiated prednisolone for acute asthma in children of school age: randomised controlled crossover trial

OBJECTIVE

To evaluate the efficacy of a short course of parent initiated oral prednisolone for acute asthma in children of school age.

DESIGN

Double blind, randomised, placebo controlled, crossover trial in which episodes of asthma, rather than participants, were randomised to treatment.

SETTING

The Barwon region of Victoria, Australia.

PARTICIPANTS

Children aged 5-12 years with a history of recurrent episodes of acute asthma.

INTERVENTION

A short course of parent initiated treatment with prednisolone (1 mg/kg a day) or placebo.

MAIN OUTCOME MEASURES

The primary outcome measure was the mean daytime symptom score over seven days. Secondary outcome measures were mean night time symptom score over seven days, use of health resources, and school absenteeism.

RESULTS

230 children were enrolled in the study. Over a three year period, 131 (57%) of the participants contributed a total of 308 episodes of asthma that required parent initiated treatment: 155 episodes were treated with parent initiated prednisolone and 153 with placebo. The mean daytime symptom score was 15% lower in episodes treated with prednisolone than in those treated with placebo (geometric mean ratio 0.85, 95% CI 0.74 to 0.98; P=0.023). Treatment with prednisolone was also associated with a 16% reduction in the night time symptom score (geometric mean ratio 0.84, 95% CI 0.70 to 1.00; P=0.050), a reduced risk of health resource use (odds ratio 0.54, 95% CI 0.34 to 0.86; P=0.010), and reduced school absenteeism (mean difference -0.4 days, 95% CI -0.8 to 0.0 days; P=0.045).

CONCLUSION

A short course of oral prednisolone initiated by parents when their child experiences an episode of acute asthma may reduce asthma symptoms, health resource use, and school absenteeism. However, the modest benefits of this strategy must be balanced against potential side effects of repeated short courses of an oral corticosteroid.

TRIAL REGISTRATION

ISRCTN 26232583.

Does pre-hospital telephone communication with a clinician result in more appropriate medication administration by parents during childhood asthma exacerbations?

BACKGROUND

The National Heart, Lung and Blood Institute asthma guidelines recommend that parents communicate with a clinician during childhood asthma exacerbations when symptoms worsen or do not improve with initial therapy. This study tested the hypothesis that communication by parents with a clinician before an Emergency Department visit was associated with more appropriate medication administration for children with asthma exacerbations.

METHODS

This was a retrospective cohort study using data gathered from parents of children presenting with an asthma exacerbation to the emergency department. The communicating cohort included parents who communicated by telephone with a clinician during the exacerbation and the non-communicating cohort included parents who did not. Multivariate logistic regression models were used to test three hypotheses; communication with a clinician is associated with (1) administration of short-acting beta-agonists (SABAs), (2) increased dosing frequency of SABAs, and (3) administration of an oral corticosteroid.

RESULTS

A total of 199 subjects were enrolled, with 104 (52.3%) in the communicating and 95 (47.7%) in the non-communicating cohort. There was an association between communication and provider practice type, with children who received routine care from a private practice provider more likely to communicate with the clinician than children in hospital-based clinics or community health centers (Adjusted OR 1.9, 95% CI 1.0-3.7). Impoverished children and children insured by Medicaid were less likely to communicate with a clinician (controlling for provider type). Parents who communicated with a clinician were more likely to administer a SABA (adjusted OR 3.6, 95% CI 1.3-9.4) and an oral corticosteroid (adjusted OR 3.3, 95% CI 1.3-8.4) but were not more likely to administer a SABA with increased dosing frequency (adjusted OR 0.9, 95% CI 0.5-1.6).

CONCLUSIONS

Parents of children with asthma exacerbations who communicated with clinicians were more likely to administer SABAs and an oral corticosteroid before bringing their child to an emergency department. Frequency of SABA dosing was not associated with communication. Clinicians providing telephone advice to parents need to provide explicit instructions about medication administration, emphasizing the frequency with which SABAs should be administered.

Pediatric asthma and related allergic and nonallergic diseases: patient-oriented evidence-based essentials that matter

Asthma is the most common medical diagnosis among hospitalized children. In the USA, asthma has accounted for approximately 15% of nonsurgical admissions to hospital in the pediatric age group. Asthma is also one of the leading causes for emergency care requirements, one of the leading causes for missed school, and a cause for considerable morbidity, disability and occasional mortality at all ages. Despite these discouraging statistics, convincing data indicate that this failure of asthma management is not the result of inadequate therapeutic potential, but instead represents ineffective delivery of medical care. Management of asthma and its major co-morbidities, allergic and nonallergic rhinitis, and atopic dermatitis requires a knowledge of the alternative therapies, natural history, and educational techniques for providing patients and families with the ability to manage these troublesome chronic disorders.

Parent-initiated oral corticosteroid therapy for acute asthma: a survey of current practice

AIM

To determine (i) the proportion of doctors who recommend parent-initiated oral corticosteroids (PIOCS) for acute asthma; and (ii) the proportion of parents who have received this advice.

METHODS

(i) An internet-based survey of doctors involved in the care of children with asthma; and (ii) a questionnaire-based survey of parents of children aged 4-13 years who were identified from a random sample of primary schools within the Barwon region of Victoria.

RESULTS

Eight-five per cent (95% confidence interval 80.0-89.1%) of responding doctors reported recommending PIOCS to parents of children with asthma. However, only 16.5% (95% confidence interval 14.2-18.7%) of parents of children with recent asthma symptoms report that they have received such advice.

CONCLUSION

The majority of responding doctors involved in the care of children with asthma report recommending PIOCS to parents. By contrast, a minority of parents of children with asthma report that they have received such advice.

Current management of status asthmaticus in the pediatric ICU

Status asthmaticus (SA) in the pediatric ICU (PICU) can progress to a life-threatening emergency. The goal of management is to improve hypoxemia, improve bronchoconstriction, and decrease airway edema through the administration of continuous nebulized beta2 adrenergic agonist with intermittent anticholinergics, corticosteroids, and oxygen. Adjunctive therapies, such as magnesium, methylxanthines, intravenous beta-agonists, heliox, and noninvasive ventilation should be considered in the child who fails to respond to initial therapies. The restoration of adequate pulmonary functions, resolution of airway obstruction, and avoidance of mechanical ventilation should guide management. This article reviews the pathophysiology, assessment, and management of the child who has SA in the PICU to provide the critical care nurse with current information to facilitate optimal care.

[Comparative efficacy of oral deflazacort versus oral prednisolone in children with moderate acute asthma]

OBJECTIVES

To assess the efficacy and tolerability of oral deflazacort versus oral prednisolone in acute moderate asthma in children.

PATIENTS AND METHODS

We performed a prospective, randomized, parallel group trial of children aged 6 to 14 years old with a diagnosis of asthma who presented to the pediatric emergency department for moderate asthma exacerbation. All patients were administered short-acting beta2-adrenergic agonists. The intervention groups received either oral deflazacort (1.5 mg/kg) or prednisolone (1 mg/kg) for 7 days. The primary outcome measure was forced expiratory volume in 1 second (FEV1) and secondary outcome measures were pulmonary symptom score index, peak expiratory flow rate (PEFR), hospitalization rate and the use of rescue beta2-agonists. Patients were evaluated at the start of treatment (visit 1), on day 2 (visit 2) and on day 7 (visit 3).

RESULTS

Of the 54 children enrolled, two were hospitalized on visit 2 (one from each group). Baseline clinical data were similar in both groups: FEV1: 53 and 51 %; bronchodilator test: 119 and 121 %; PEFR: 169 and 165 L/min; symptom score: 6 and 6.5 for the deflazacort and prednisolone groups, respectively. On visit 2, all measures improved: FEV1: 122.2 and 126.5 % (p < 0.05); PEFR: 164 and 149 L/min (p < 0.05); symptom score: -4.4 and -3.8 (p < 0.05), without significant differences between groups. On visit 3 all variables continued to show improvement: FEV1: 133.2 and 132.5 % (p < 0.05); PEFR: 1115.7 and 187.6 L/min (p < 0.05); symptom score: -5.4 and -5.9 (p < 0.05), without significant differences between groups. No adverse effects were reported.

CONCLUSIONS

Deflazacort and prednisolone show similar efficacy in improving pulmonary function and in producing clinical improvement in the management of acute moderate asthma in children.

Treating exacerbations of asthma in children: the role of systemic corticosteroids

OBJECTIVE

To review the use of systemic corticosteroids to treat recurrent, acute asthma episodes in children, with a focus on the role of oral corticosteroids.

METHODS

A comprehensive review of the literature was performed using the Medline database (January 1966-October 2002) and the Embase database (January 1980-August 2002).

RESULTS

The significant findings of 17 selected, controlled clinical trials of oral corticosteroids (OCSs) for acute exacerbations of asthma in children, compared with placebo or with other formulations of corticosteroids, can be summarized as follows: 1) OCSs are effective for the outpatient treatment of acute asthma, 2) pulmonary function tests may not be the best means of assessing the efficacy of OCSs for acute asthma, 3) early administration of OCSs for acute asthma reduces hospitalizations, 4) the critical factor for a positive outcome is early administration of the corticosteroid, and 5) OCSs are preferred for the outpatient treatment of acute asthma.

CONCLUSIONS

Early treatment of acute asthma symptoms with OCSs in children with a pattern of recurrent acute asthma may decrease the severity of acute asthma episodes and reduce the likelihood of subsequent relapses. Attention should be given to identifying these children and standardizing a treatment approach based on accepted, consistent definitions of what constitutes an asthma exacerbation and recurrence. A suggested protocol is described.