Evaluation and treatment of critical asthma syndrome in children

AARC and PALISI Clinical Practice Guideline: Pediatric Critical Asthma

To address the lack of guidance for clinicians in their care of children with critical asthma, a multidisciplinary team of medical providers used Grading of Recommendations, Assessment, Development, and Evaluation methodology to make the following recommendations: 1. We suggest the use of continuous inhaled short-acting β agonist (SABA) over frequent intermittent SABA in children treated for critical asthma. (Conditional recommendation, very low certainty of evidence) 2. We suggest the use of either high- or low-dose continuous inhaled SABA regimens in children treated for critical asthma. (Conditional recommendation, very low certainty of evidence) 3. We suggest the use of either dexamethasone or methylprednisolone (or an equivalent dose of prednisone/prednisolone) for children treated for critical asthma. (Conditional recommendation, very low certainty of evidence) 4. We suggest the use of intravenous (IV) magnesium (intermittent or continuous) as an adjunct therapy in children treated for critical asthma. (Conditional recommendation, low certainty of evidence) 5. We cannot recommend for or against the use of IV methylxanthines as an adjunct therapy in children treated for critical asthma. (Conditional recommendation, very low certainty of evidence) 6. We suggest the use of an IV SABA infusion as an adjunct therapy in children treated for critical asthma. (Conditional recommendation, low certainty of evidence) 7. We cannot recommend for or against the application of high-flow nasal cannula versus conventional oxygen therapy in children presenting with critical asthma with persistent hypoxemia and/or respiratory distress. (Conditional recommendation, very low certainty of evidence) 8. We suggest the use of bi-level positive airway pressure over conventional oxygen therapy in children presenting with critical asthma with persistent hypoxemia and/or respiratory distress. (Conditional recommendation, very low certainty of evidence) 9. We cannot recommend for or against the application of bi-level positive airway pressure over high-flow nasal cannula for children hospitalized with critical asthma with persistent hypoxemia and/or respiratory distress. (Conditional recommendation, very low certainty of evidence) 10. We cannot recommend for or against the application of heliox in children treated for critical asthma. (Conditional recommendation, very low certainty of evidence) 11. We suggest the use of a dedicated protocol or pathway for managing children treated for critical asthma. (Conditional recommendation, low certainty of evidence).

Oral Nutrition During Continuous Albuterol for Pediatric Critical Asthma: A Matched Cohort Study

Purpose

The practice of withholding oral nutrition for children hospitalized for critical asthma receiving continuous albuterol is not evidence based. We sought to characterize oral nutrition practices in this population and estimate the frequency of aspiration-related respiratory failure.

Methods

We performed a single-center retrospective, matched cohort study of children 3-17 years of age admitted to a pediatric intensive care unit from Oct 2020 to May 2023 for critical asthma receiving continuous albuterol. Cases provided oral nutrition were matched 1:2 to controls withheld nutrition by age and National Heart Lung and Blood Institute asthma severity classification. The primary outcome was aspiration-related respiratory failure defined as any respiratory support escalation following observed aspiration. Descriptive data included demographics, anthropometrics, pediatric asthma severity scores, adjunct asthma interventions, continuous albuterol duration, mortality, and length of stay.

Results

Of 36 cases and 72 matched controls, the mean age was 9.1±3.9 years and 66.7% had moderate-severe persistent asthma. Cases and controls had comparable anthropometrics and admission pediatric asthma severity scores. No aspiration-related respiratory failure events were observed even among those receiving nutrition concurrent to noninvasive ventilation. Compared to controls, cases experienced a longer continuous albuterol duration (median: 1.1 [interquartile range: 0.7-1.8] versus 0.7 [interquartile range: 0.3-1.3] days, p<0.001). No differences in length of stay, adjunct interventions, endotracheal intubation rates, and mortality were observed between cases and controls.

Conclusion

For children hospitalized for critical asthma, oral nutrition during continuous nebulized albuterol appeared well tolerated. While prospective validation is required, the practice of withholding oral nutrition for continuous albuterol administration may be unwarranted.

Functional immunophenotyping of children with critical status asthmaticus identifies differential gene expression responses in neutrophils exposed to a poly(I:C) stimulus

The host immune response to a viral immune stimulus has not been examined in children during a life-threatening asthma attack. We determined whether we could identify clusters of children with critical asthma by functional immunophenotyping using an intracellular viral analog stimulus. We performed a single-center, prospective, observational cohort study of 43 children ages 6-17 years admitted to a pediatric intensive care unit for an asthma attack between July 2019 to February 2021. Neutrophils were isolated from children, stimulated overnight with LyoVec poly(I:C), and mRNA was analyzed using a targeted Nanostring immunology array. Network analysis of the differentially expressed transcripts for the paired LyoVec poly(I:C) samples was performed. We identified two clusters by functional immunophenotyping that differed by the Asthma Control Test score. Cluster 1 (n = 23) had a higher proportion of children with uncontrolled asthma in the four weeks prior to PICU admission compared with cluster 2 (n = 20). Pathways up-regulated in cluster 1 versus cluster 2 included chemokine receptor/chemokines, interleukin-10 (IL-10), IL-4, and IL-13 signaling. Larger validation studies and clinical phenotyping of children with critical asthma are needed to determine the predictive utility of these clusters in a larger clinical setting.

Management of Acute Asthma in Children

Asthma is the most common disease of childhood globally and acute asthma is the most significant risk factor for asthma-related death and chronic complications. This article will aim to synthesize the most up-to-date research and translate it into a more practical guide to managing acute asthma on a more daily basis. The use of clinical severity score is reviewed alongside the use of history and clinical findings in making objective assessments of patients presenting with acute asthma. Practical evidence-based pathways and a stepwise approach are provided for management of acute asthma in the home, outpatient, emergency, and intensive care settings. In doing so, popular myths are dispelled and practices in relation to management of acute asthma and use of asthma related medications are clarified. Having a standardized approach to management of acute asthma will bring us one step closer to reducing exacerbations and achieving the goal of having zero tolerance towards exacerbations.

State-of-the-Art Review of The Application and Development of Various Methods of Aerosol Therapy

Aerosol therapy is a rapidly developing field of science. Due to a number of advantages, the administration of drugs to the body with the use of aerosol therapy is becoming more and more popular. Spraying drugs into the patient's lungs has a significant advantage over other methods of administering drugs to the body, including injection and oral methods. In order to conduct proper and effective aerosol therapy, it is necessary to become familiar with the basic principles and applications of aerosol therapy under various conditions. The effectiveness of inhalation depends on many factors, but most of all on: the physicochemical properties of the sprayed system, the design of the medical inhaler and its correct application, the dynamics of inhalation (i.e. the frequency of breathing and the volume of inhaled air). It is worth emphasizing that respiratory system diseases are one of the most frequently occurring and fastest growing diseases in the world. Accordingly, in recent years, a significant increase in the number of new spraying devices and pharmaceutical drugs for spraying has appeared on the market. It should also be remembered that the process of spraying a liquid is a complicated and complex process, and its efficiency is very often characterized by the use of micro- and macro parameters (including average droplet diameters or the spectrum of droplet diameter distribution). In order to determine the effectiveness of the atomization process and in the delivery of drugs to the patient's respiratory tract, the analysis of the size of the generated aerosol droplets is most often performed. Based on the proposed literature review, it has been shown that many papers dealt with the issues related to aerosol therapy, the selection of an appropriate spraying device, the possibility of modifying the spraying devices in order to increase the effectiveness of inhalation, and the possibility of occurrence of certain discrepancies resulting from the use of various measurement methods to determine the characteristics of the generated aerosol. The literature review presented in the paper was prepared in order to better understand the spraying process. Moreover, it can be helpful in choosing the right medical inhaler for a given liquid with specific rheological properties. The experimental data contained in this study are of great cognitive importance and may be of interest to entities involved in pharmaceutical product engineering (in particular in the case of the production of drugs containing liquids with complex rheological properties).

Management of Children with Acute Asthma Attack: A RAND/UCLA Appropriateness Approach

Bronchial asthma is the most frequent chronic disease in children and affects up to 20% of the pediatric population, depending on the geographical area. Asthma symptoms vary over time and in intensity, and acute asthma attack can resolve spontaneously or in response to therapy. The aim of this project was to define the care pathway for pediatric patients who come to the primary care pediatrician or Emergency Room with acute asthmatic access. The project was developed in the awareness that for the management of these patients, broad coordination of interventions in the pre-hospital phase and the promotion of timely and appropriate assistance modalities with the involvement of all health professionals involved are important. Through the application of the RAND method, which obliges to discuss the statements derived from the guidelines, there was a clear increase in the concordance in the behavior on the management of acute asthma between primary care pediatricians and hospital pediatricians. The RAND method was found to be useful for the selection of good practices forming the basis of an evidence-based approach, and the results obtained form the basis for further interventions that allow optimizing the care of the child with acute asthma attack at the family and pediatric level. An important point of union between the primary care pediatrician and the specialist hospital pediatrician was the need to share spirometric data, also including the use of new technologies such as teleconsultation. Monitoring the progress of asthma through spirometry could allow the pediatrician in the area to intervene early by modifying the maintenance therapy and help the patient to achieve good control of the disease.

Acute severe asthma: management and treatment

Patients with acute asthma attack usually access the emergency room with severe functional impairment, despite low perception of symptoms. In this scenario, early functional assessment is essential focusing on vital parameters and respiratory function, alongside perceived dyspnea. Impairment of ventilatory mechanics due to progressive dynamic pulmonary hyperinflation should be promptly treated with medical inhalation and/or intravenous therapy, reserving intensive treatment in case of non-response and/or worsening of the clinical conditions. Therapeutic planning at patient's discharge is no less important than treatment management during emergency room access as educating the patient about therapeutic adherence significantly impact long-term outcomes of asthma. With this review we aim at exploring current evidence on acute asthma attack management, focusing of pharmacological and ventilatory strategies of care and highlighting the importance of patient education once clinical stability allows discharge from the emergency department.

Emergency department treatment of asthma in children: A review

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.

Non-invasive positive pressure ventilation for acute asthma in children

BACKGROUND

Asthma is one of the most common reasons for hospital admission among children and constitutes a significant economic burden. Use of non-invasive positive pressure ventilation (NPPV) in the care of children with acute asthma has increased even though evidence supporting the intervention has been considered weak and clinical guidelines do not recommend the intervention. NPPV might be an effective intervention for acute asthma, but no systematic review has been conducted to assess the effects of NPPV as an add-on therapy to usual care in children with acute asthma.

OBJECTIVES

To assess the benefits and harms of NPPV as an add-on therapy to usual care (e.g. bronchodilators and corticosteroids) in children with acute asthma.

SEARCH METHODS

We identified trials from the Cochrane Airways Group Specialised Register (CAGR). The Register contains trial reports identified through systematic searches of bibliographic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED and PsycINFO, and by handsearching of respiratory journals and meeting abstracts. We also conducted a search of ClinicalTrials.gov (www.ClinicalTrials.gov) and the WHO trials portal (www.who.int/ictrp/en/). We searched all databases from their inception to February 2016, with no restriction on language of publication.

SELECTION CRITERIA

We included randomised clinical trials (RCTs) assessing NPPV as add-on therapy to usual care versus usual care for children (age < 18 years) hospitalised for an acute asthma attack.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts. We retrieved all relevant full-text study reports, independently screened the full text, identified trials for inclusion and identified and recorded reasons for exclusion of ineligible trials. We resolved disagreements through discussion or, if required, consulted a third review author. We recorded the selection process in sufficient detail to complete a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flow diagram and 'Characteristics of excluded studies' table. We identified the risk of bias of included studies to reduce the risk of systematic error. We contacted relevant study authors when data were missing.

MAIN RESULTS

We included two RCTs that randomised 20 participants to NPPV and 20 participants to control. We assessed both studies as having high risk of bias; both trials assessed effects of bilateral positive airway pressure (BiPAP). Neither trial used continuous positive airway pressure (CPAP). Controls received standard care. Investigators reported no deaths and no serious adverse events (Grades of Recommendation, Assessment, Development and Evaluation (GRADE): very low quality of evidence due to serious risk of bias and serious imprecision of results). Both trials showed a statistically significant reduction in symptom score. One trial did not report a standard deviation (SD), but by using an estimated SD, we found a statistically significantly reduced asthma symptom score (mean difference (MD) -2.50, 95% confidence interval (CI) -4.70 to -0.30, P = 0.03, 19 participants, GRADE: very low quality of evidence). In the other trial, NPPV was associated with a lower total symptom score (5.6 vs 1.9, 16 participants, very low quality of evidence) before cross-over, but investigators did not report an SD, nor could it be estimated from the first phase of the trial, before the cross-over. These gains could be clinically relevant, as a reduction of three or more points in symptom score is considered a clinically meaningful change. Researchers documented five dropouts (12.5%), four of which were due to intolerance to NPPV, and one to respiratory failure requiring intubation. Owing to insufficient reporting in the latter trial and use of different scoring systems, it was not possible to conduct a meta-analysis nor a Trial Sequential Analysis.

AUTHORS' CONCLUSIONS

Current evidence does not permit confirmation or rejection of the effects of NPPV for acute asthma in children. Large RCTs with low risk of bias are warranted.

Asthma-associated comorbidities in children with and without secondhand smoke exposure

BACKGROUND

Secondhand smoke (SHS) exposure is known to trigger asthma, but asthma disease severity and comorbidities in children exposed to SHS are not very well quantified.

OBJECTIVE

To identify comorbidities and understand health care usage in children with asthma exposed to SHS (cases) compared with children with asthma but without SHS exposure (controls).

METHODS

A retrospective nested matched case-and-control study was conducted with children 5 to 18 years old who were enrolled in the Pediatric Asthma Management Program. Pulmonary function testing (spirometry, methacholine challenges, and exhaled nitric oxide) and body mass index were reviewed. Influenza vaccination rates, oral steroid usage, emergency department visits, and hospitalizations were assessed. Network analysis of the 2 groups also was conducted to evaluate for any associations between the variables.

RESULTS

Cases had significantly higher body mass index percentiles (>75%, odds ratio [OR] 1.64, 95% confidence interval [CI] 1.22-2.2, P = .001). Cases were less likely to have had a methacholine challenge (OR 0.49, 95% CI 0.36-0.68, P < .001) and an exhaled nitric oxide (OR 0.6, 95% CI 0.37-0.97, P = .04) performed than controls. The ratio of forced expiration volume in 1 second to forced vital capacity and forced expiration volume in 1 second were lower in cases than in controls (P < .05). Cases were less likely to have received an influenza vaccination (OR 0.61, 95% CI 0.45-0.82, P = .001) than controls. Unsupervised multivariable network analysis suggested a lack of discrete and unique subgroups between cases and controls.

CONCLUSION

Children with asthma exposed to SHS are more likely to have comorbid conditions such as obesity, more severe asthma, and less health care usage than those not exposed to SHS. Smoking cessation interventions and addressing health disparities could be crucial in this vulnerable population.

An overview of integrative therapies in asthma treatment

Treatment of asthma lends itself to an integrative medicine approach due to the multifactorial nature of the disease. It is well established that asthma has a neuromuscular component (bronchospasm), an immunological component (inflammation), and a psychological component. This encourages the use of diverse approaches to address all avenues of pathophysiology, aiming for the most effective blend of treatment approaches possible. Integrative medicine is defined by NIH NCCAM ( http://nccam.nih.gov ) as medicine that blends the use of evidence-based complementary therapies with conventional medicine. Statistics from the 2007 National Health Interview Survey (NHIS), conducted by the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS), showed that approximately four out of 10 adults and approximately one in nine children and more than 50 % of children living with chronic illness, including asthma, used complementary therapies in the USA in 2007. Asthma and allergies rank among the top 15 most common medical conditions in which integrative therapies are used in both children and adults. To date, integrative treatment approaches with some evidence for benefit in asthma treatment include the following: nutrition modification, mind-body medicine, physical activity, and certain dietary supplement interventions.