Predicting hospitalization in children with acute asthma

A Retrospective Audit of Pharmacologic and Non-Pharmacologic Management of Childhood Acute Asthma Exacerbation at Usmanu Danfodiyo University Teaching Hospital, Sokoto: Adherence to Global Treatment Guidelines

Background

Adequate management of childhood acute asthma exacerbation requires optimal non-pharmacotherapy and pharmacotherapy. Global asthma guidelines provide critical information and serves as a quick reference decision-support material for clinicians.

Objectives

We aimed at evaluating hospital management of childhood acute asthma exacerbation to ascertain its conformity to the global treatment guidelines, and to identify factors that predict short or prolonged observation in the hospital.

Method

This was a retrospective audit of the management of acute asthma exacerbation in children seen between 01 January 2017 and 31 December 2018 at Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria. Relevant data on demography, asthma triggers and severity, functional and clinical diagnoses, types of controller medications used before and after presentation, non-pharmacotherapy and pharmacotherapy instituted during presentation, duration of observation in the hospital, and treatment outcomes were extracted from the case file of each eligible patient.

Results

A total of 119 children presented with features of suspected acute asthma exacerbations during the study period but only 63 (52.9%) that met the inclusion criteria for the study were included for analysis. The 63 children that were evaluated had mild (47; 74.6%) and moderate (16; 25.4%) acute asthma exacerbations. Their median (interquartile range) age was 8 (5–15) years. More males (36; 57.1%) than females (27; 42.9%) presented with features of the condition. Majority (50; 79.8%) of the patients had at least one trigger factor and of the 73 trigger factors reported, cold weather (19; 26.0%) was the commonest. Nebulized salbutamol (48; 76.5%), in addition to intravenous (23; 57.9%) and oral (17; 42.5%) corticosteroids, was used during hospital treatment. Patients were discharged mostly on short course of oral corticosteroid only (37; 58.8%). Of the 17 major recommendations in the Global Initiative for Asthma (GINA) guidelines, good (5; 29.4%), moderate (7; 41.2%), and poor (5; 29.4%) levels of adherence were observed. Specifically, moderate and poor levels of adherence were observed in the management of 61(96.8%) and 2(3.2%) patients, respectively. The odds of admission for ≤12 h were higher for female children and patients with mild cases.

Conclusion

Good and moderate adherence levels to 12 of the 17 GINA recommendations were observed in our center. Nonetheless, reinforcement of institutional guidelines for acute asthma management is suggested to further improve the quality of care of childhood acute asthma exacerbations.

Economic Burden of Pediatric Asthma in Turkey: A Cost of Illness Study from Payer Perspective

OBJECTIVES

To estimate economic burden of pediatric asthma in Turkey from payer perspective.

MATERIALS AND METHODS

This cost of illness study was based on identification of per patient annual direct medical costs for the management of pediatric asthma in Turkey from payer perspective. Average per patient direct medical cost was calculated based on cost items related to outpatient visits, laboratory and radiological tests, hospitalizations and interventions, drug treatment and equipment, and co-morbidities/complications.

RESULTS

Based on total annual per patient costs calculated for outpatient admission ($113.14), laboratory-radiological tests ($35.94), hospitalizations ($725.92), drug treatment/equipment ($212.90) and co-morbidities/complications ($144.62) cost items, total per patient annual direct medical cost related to management of pediatric asthma was calculated to be $1,232.53 from payer perspective. Hospitalizations and interventions (58.9%) was the main cost driver. Direct cost for managing controlled and uncontrolled pediatric asthma were calculated to be $530.17 [key cost driver: drugs/equipment (40.0%)] and $1,023.16 [key cost driver: hospitalization/interventions (59.0%)], respectively.

CONCLUSION

Our findings indicate that managing patients with pediatric asthma pose a considerable burden to health economics in Turkey, with hospitalizations identified as the main cost driver and two-fold cost increment in case of uncontrolled disease.

Mesh nebulizer is as effective as jet nebulizer in clinical practice of acute asthma in children

Background/aim

The aim of this study was to compare the effect of salbutamol delivered to children by jet nebulizer (JN) and mesh nebulizer (MN).

Materials and methods

Children admitted with acute asthma were treated with 3 doses of nebulized salbutamol, 1 given by MN. The patients’ vital signs, lung function measurements, modified pulmonary index score (MPIS), and whole body plethysmography (WBP) measurements were evaluated before and 20 min after each dose of salbutamol.

Results

Thirty-onechildren [9.5 (6.4–17.2) years, 67.7% male, 32.3% female] with mild (67.7%) and moderate (32.3%) asthma attacks were included in the study. The improvements with MN were comparable with JN in terms of changes in pretreatment and posttreatment forced expiratory volume in the first second (FEV1) (2.57 ± 4.57, 3.65 ± 5.44; P = 0.44), forced vital capacity (FVC) (2.52 ± 5.29, 4.17 ± 7.54; P = 0.28), heart rate (7.33 ± 10.21, 4.14 ± 9.32; P = 0.24), peripheral capillary oxygen saturation (SpO2) (0.38 ± 0.23, 0.43 ± 0.15; P = 0.83), and modified pulmonary index score (MPIS) (−6.30 ± 22.70, −8.77 ± 25.46; P = 0.70). The pre- and posttreatment values of total lung capacity (TLC), residual volume (RV), specific conductance (sGaw), and RV/TLC were similar for the JN and MN groups. Adverse effects were not different: however, complaints of palpitation were significantly higher in the posttreatment MN group than the pretreatment MN group (32.3% vs 9.7%, respectively, P = 0.016).

Conclusions

These findings support the previous evidence found in studies of adults that MN is as effective as and as safe as JN in the treatment of acute asthma in children.

Genetic determinants of acute asthma therapy response in children with moderate-to-severe asthma exacerbations

BACKGROUND

We documented inter-individual variability in the response to acute asthma therapy in children, attributed in part to five clinical factors (oxygen saturation, asthma severity score, virus detection, fever, symptoms between exacerbations; DOORWAY study). The contribution of genetic determinants of failure of acute asthma management have not been elucidated.

OBJECTIVE

We aim to determine single nucleotide polymorphisms (SNP) associated with emergency department (ED) management failure in children.

METHODS

A prospective cohort of 591 Caucasian children aged 1-17 years with moderate-to-severe asthma managed with standardized protocol were included. We examined 53 SNPs previously associated with asthma development, phenotypes, or bronchodilator or corticosteroids response. Associations between SNPs and management failure (hospitalization, active asthma management ≥8 h in ED, or a return visit within 72 h for one of two previous criteria) were examined using logistic regression, adjusting for the five clinical predictors of management failure.

RESULTS

Four-hundred ninety-one subjects had complete clinical data and usable DNA samples. While controlling for clinical determinants, rs295137 in SPATS2L (OR = 1.77, 95%CI: 1.17, 2.68) was significantly associated with increased odds of ED management failure. Two SNPs in IL33 were associated with decreased odds of ED management failure: rs7037276 (OR = 0.55, 95%CI: 0.33, 0.90), and rs1342326 (OR = 0.52, 95%CI: 0.32, 0.86). The addition of these three SNPs to the clinical predictors significantly improved the model's predictive performance (P < 0.0004).

CONCLUSION

Three SNPs were significantly associated with ED management failure in addition to clinical predictors, contributing to inter-individual variability. None has been previously associated with treatment response to acute asthma management.

Repeated doses of salbutamol and aeroallergen sensitisation both increased salbutamol-induced hypoxia in children and adolescents with acute asthma

AIM

We aimed to identify the frequency, magnitude and risk factors of salbutamol-induced hypoxia in children with acute asthma.

METHODS

This study was conducted at Hacettepe University on children who presented to the paediatric allergy clinic or the paediatric emergency room with acute asthma between July 2014 and June 2015. Vital signs, pulse oximetry-defined oxygen saturation and modified pulmonary index scores were evaluated before and after the first, second and third doses of nebulised salbutamol and repeated one and 10 days later.

RESULTS

We included 304 patients (65.7% male) from median age of 5.3 years (range 1-18 years). Salbutamol-induced hypoxia was detected in 14.7%, 3.9% and 1.3%, respectively, after the first, second and third doses of salbutamol. The risk factors for hypoxia were younger age and a higher modified pulmonary index score, but the risk factors for salbutamol-induced hypoxia were the number of salbutamol doses given in the last six hours and the presence of aeroallergen sensitisation. The maximum decrease in oxygen saturation after salbutamol was %5.

CONCLUSION

Although bronchodilators are the first-line treatment for acute asthma, they caused modest hypoxaemia, especially at repeated doses and, or, in patients with aeroallergen sensitisation.

Clinical Utility of the Modified Pulmonary Index Score as an Objective Assessment Tool for Acute Asthma Exacerbation in Children

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.

Usefulness of modified Pulmonary Index Score (mPIS) as a quantitative tool for the evaluation of severe acute exacerbation in asthmatic children

BACKGROUND

Acute exacerbation of asthma is divided qualitatively into mild, moderate, and severe attacks and respiratory failure. This system is, however, not suitable for estimating small changes in respiratory condition with time and for determining the efficacy of treatments, because it has a qualitative, but not quantitative nature.

METHODS

To evaluate the usefulness of quantitative estimation of asthma exacerbation, modified Pulmonary Index Score (mPIS) values were measured in 87 asthmatic children (mean age, 5.0 ± 0.4 years) during hospitalization. mPIS was calculated by adding the sum of scores for 6 items (scores of 0-3 were given for each item). These consisted of heart rate, respiratory rate, accessory muscle use, inspiratory-to-expiratory flow ratio, degree of wheezing, and oxygen saturation in room air. Measurements were made at visits and at hospitalization and were then made twice a day until discharge.

RESULTS

mPIS values were highly correlated among raters. mPIS values at visits were 9.1 ± 0.1 and 12.6 ± 0.4 in subjects with moderate and severe attacks, respectively (p < 0.001). mPIS values of subjects requiring continuous inhalation therapy (CIT) with isoproterenol in addition to systemic steroids were significantly higher than the values of those without CIT (12.0 ± 0.5 and 9.3 ± 0.2, respectively, p < 0.001). A score of 10 was suggested to be the optimal cutoff for distinguishing between subjects requiring and not requiring CIT, from the perspectives of both sensitivity and specificity. mPIS at hospitalization correlated well with the period until discharge, suggesting that this score was a useful predictor for the clinical course after hospitalization.

CONCLUSIONS

mPIS could be a useful tool for several aspects during acute asthma attacks, including the determination of a treatment plan, and prediction of the period of hospitalization in admitted patients, although prospective studies would be required to establish our hypothesis.

Predictors of hospitalization for asthma in children: results of a 1-year prospective study

INTRODUCTION

Although hospital admissions for pediatric asthma constitute a significant problem in high-income countries, they are an even greater health problem in low- and middle-income countries (LMIC). However, previous studies that aimed to identify predictors of hospital admission for asthma in children have mainly been conducted in high-income countries, and these findings might not be applicable to LMIC.

METHODS

In a prospective cohort study, we aimed to identify predictors of hospital admission for asthma, including measures of parental knowledge about asthma and maternal depression level, in a population of children aged 1-18 years living in urban Bogota, Colombia hospitalized for acute asthma symptoms, over a 6-month period.

RESULTS

Out of the total of 101 included patients, 37 (36.6%) had at least one hospital admission for asthma during the year following admission. After controlling for the age of the patients, dog ownership in the previous 12 months, asthma severity variables in the previous 6 months, maternal allergic rhinitis, level of maternal education, and measures of parental knowledge about asthma and maternal depression level, we found that maternal smoking (IRR, 3.12; 95% confidence interval [95% CI], 1.12-8.68; P = 0.029) was the only independent predictor of hospital admissions due to asthma exacerbations in the year following admission to the study.

CONCLUSIONS

In a population of asthmatic Latino children admitted to hospital for an asthma exacerbation, approximately one-third of the patients had at least one hospital admission for asthma during the year following admission, and maternal smoking was the only independent predictor of these hospitalizations.