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Rojas-Anaya H, Kapur A, Roberts G, Roland D, Gupta A, Lazner M, Bayreuther J, Pappachan J, Jones C, Bremner S, Cantle F, Seddon P. High-Flow Humidified Oxygen as an Early Intervention in Children With Acute Severe Asthma: Protocol for a Feasibility Randomized Controlled Trial. JMIR Res Protoc 2024; 13:e54081. [PMID: 38546733 PMCID: PMC11009849 DOI: 10.2196/54081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/25/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Acute severe asthma (ASA) is a leading cause of hospital attendance in children. Standard first-line therapy consists of high-dose inhaled bronchodilators plus oral corticosteroids. Treatment for children who fail to respond to first-line therapy is problematic: the use of intravenous agents is inconsistent, and side effects are frequent. High-flow humidified oxygen (HiFlo) is widely used in respiratory conditions and is increasingly being used in ASA, but with little evidence for its effectiveness. A well-designed, adequately powered randomized controlled trial (RCT) of HiFlo therapy in ASA is urgently needed, and feasibility data are required to plan such an RCT. In this study, we describe the protocol for a feasibility study designed to fill this knowledge gap. OBJECTIVE This study aims to establish whether a full RCT of early HiFlo therapy in children with ASA can be conducted successfully and safely, to establish whether recruitment using deferred consent is practicable, and to define appropriate outcome measures and sample sizes for a definitive RCT. The underlying hypothesis is that early HiFlo therapy in ASA will reduce the need for more invasive treatments, allow faster recovery and discharge from hospital, and in both these ways reduce distress to children and their families. METHODS We conducted a feasibility RCT with deferred consent to assess the use of early HiFlo therapy in children aged 2 to 11 years with acute severe wheeze not responding to burst therapy (ie, high-dose inhaled salbutamol with or without ipratropium). Children with a Preschool Respiratory Assessment Measure score ≥5 after burst therapy were randomized to commence HiFlo therapy or follow standard care. The candidate primary outcomes assessed were treatment failure requiring escalation and time to meet hospital discharge criteria. Patient and parent experiences were also assessed using questionnaires and telephone interviews. RESULTS The trial was opened to recruitment in February 2020 but was paused for 15 months owing to the COVID-19 pandemic. The trial was reopened at the lead site in July 2021 and opened at the other 3 sites from August to December 2022. Recruitment was completed in June 2023. CONCLUSIONS This feasibility RCT of early HiFlo therapy in children with ASA recruited to the target despite major disturbances owing to the COVID-19 pandemic. The data are currently being analyzed and will be published separately. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number Registry ISRCTN78297040; https://www.isrctn.com/ISRCTN78297040. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/54081.
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Affiliation(s)
- Hector Rojas-Anaya
- University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
- Brighton and Sussex Clinical Trials Unit, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Akshat Kapur
- Respiratory Care, Royal Alexandra Children's Hospital, University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
| | - Graham Roberts
- Department of Paediatric Allergy and Respiratory Medicine, University of Southampton, Southampton, United Kingdom
- National Institute for Heath Research Southampton Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, United Kingdom
- Social science APPlied Healthcare and Improvement REsearch Group, Department of Population Health Sciences, Leicester University, Leicester, United Kingdom
| | - Atul Gupta
- Paediatric Respiratory Medicine, King's College Hospital, London, United Kingdom
| | - Michaela Lazner
- Children's Emergency Department, Royal Alexandra Children's Hospital, University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
| | - Jane Bayreuther
- Children's Emergency Department, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - John Pappachan
- National Institute for Heath Research Southampton Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Christina Jones
- School of Psychology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Stephen Bremner
- Brighton and Sussex Clinical Trials Unit, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Fleur Cantle
- Emergency Department, King's College Hospital, London, United Kingdom
| | - Paul Seddon
- Respiratory Care, Royal Alexandra Children's Hospital, University Hospitals Sussex National Health Service Foundation Trust, Brighton, United Kingdom
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2
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Al-Moamary MS, Alhaider SA, Allehebi R, Idrees MM, Zeitouni MO, Al Ghobain MO, Alanazi AF, Al-Harbi AS, Yousef AA, Alorainy HS, Al-Hajjaj MS. The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2024; 19:1-55. [PMID: 38444991 PMCID: PMC10911239 DOI: 10.4103/atm.atm_248_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 10/31/2023] [Indexed: 03/07/2024] Open
Abstract
The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.
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Affiliation(s)
- Mohamed Saad Al-Moamary
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A. Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Riyad Allehebi
- Department of Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Majdy M. Idrees
- Department of Medicine, Respiratory Division, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed O. Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohammed O. Al Ghobain
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdullah F. Alanazi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Adel S. Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hassan S. Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohamed S. Al-Hajjaj
- Department of Paediatrics, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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3
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Gray CS, Xu Y, Babl FE, Dalziel S, Powell CVE, Chong SL, Roland D, Lyttle MD, Fernandes RM, Benito J, Johnson M, Yock-Corrales A, Santhanam I, Schuh S, Cheema B, Couper J, Craig S. International perspective on research priorities and outcome measures of importance in the care of children with acute exacerbations of asthma: a qualitative interview study. BMJ Open Respir Res 2023; 10:10/1/e001502. [PMID: 36849194 PMCID: PMC9972434 DOI: 10.1136/bmjresp-2022-001502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/09/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Acute exacerbations of asthma are common in children, however, treatment decisions for severe exacerbations are challenging due to a lack of robust evidence. In order to create more robust research, a core set of outcome measures needs to be developed. In developing these outcomes, it is important to understand the views of clinicians who care for these children in particular, views that relate to outcome measures and research priorities. METHODS To determine the views of clinicians, a total of 26 semistructured interviews based on the theoretical domains framework were conducted. These included experienced clinicians from emergency, intensive care and inpatient paediatrics across 17 countries. The interviews were recorded, and later transcribed. All data analyses were conducted in Nvivo by using thematic analysis. RESULTS The length of stay in hospital and patient-focused parameters, such as timing to return to school and normal activity, were the most frequently highlighted outcome measures, with clinicians identifying the need to achieve a consensus on key core outcome measure sets. Most research questions focused on understanding the best treatment options, including the role of novel therapies and respiratory support. CONCLUSION Our study provides an insight into what research questions and outcome measures clinicians view as important. In addition, information on how clinicians define asthma severity and measure treatment success will assist with methodological design in future trials. The current findings will be used in parallel with a further Paediatric Emergency Research Network study focusing on the child and family perspectives and will contribute to develop a core outcome set for future research.
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Affiliation(s)
- Charmaine S Gray
- Adelaide Medical School, Discipline of Paediatrics, The University of Adelaide, Adelaide, South Australia, Australia .,Paediatric Emergency Department, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Yao Xu
- Zhuhai City People's Hospital, Zhuhai, Guangdong, China.,Department of Paediatrics, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Franz E Babl
- Murdoch Children's Research Institute; Departments of Paediatrics and Critical Care, University of Melbourne, Parkville, Victoria, Australia.,Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Stuart Dalziel
- Children's Emergency Department, Starship Children's Health, Auckland, New Zealand.,Surgery and Paediatrics, The University of Auckland Faculty of Health and Medical Sciences, Auckland, New Zealand
| | - Colin V E Powell
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.,Department of Emergency Medicine, Sidra Medicine, Doha, Ad-Dawhah, Qatar
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, SingHealth Paediatrics Academic Clinical Programme, Singapore
| | - Damian Roland
- SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, UK.,Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Mark D Lyttle
- Paediatric Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Research in Emergency Care Avon Collaborative Hub (REACH), University of the West of England, Bristol, UK
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria, Lisboa, Portugal.,Clinical Pharmacology Unit, University of Lisbon, Lisboa, Portugal
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital. Biocruces Bizkaia Health Research Institute, Bilbao, Spain
| | - Mike Johnson
- Department of Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Adriana Yock-Corrales
- Emergency Department, Hospital Nacional de Ninos "Dr Carlos Saenz Herrera", CCSS, San Jose, Costa Rica
| | - Indumathy Santhanam
- Regional Collaborative Center, Institute of Child Health, Madras Medical College, Egmore, Chennai, India
| | - Suzanne Schuh
- Hospital for Sick Children Research Institute, Univsersity of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Baljit Cheema
- Department of Paediatrics & Child Health, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Jenny Couper
- Adelaide Medical School, Discipline of Paediatrics, The University of Adelaide, Adelaide, South Australia, Australia
| | - Simon Craig
- Department of Paediatrics, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.,Paediatric Emergency Department, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
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McManus K, Cheetham A, Riney L, Brailsford J, Fishe JN. Implementing Oral Systemic Corticosteroids for Pediatric Asthma into EMS Treatment Guidelines: A Qualitative Study. PREHOSP EMERG CARE 2022; 27:886-892. [PMID: 36125194 PMCID: PMC10050217 DOI: 10.1080/10903127.2022.2126041] [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: 08/05/2022] [Revised: 09/05/2022] [Accepted: 09/14/2022] [Indexed: 10/14/2022]
Abstract
Introduction: Respiratory distress accounts for approximately 14% of all pediatric emergency medical services (EMS) encounters, with asthma being the most common diagnosis. In the emergency department (ED), early administration of systemic corticosteroids decreases hospital admission and speeds resolution of symptoms. For children treated by EMS, there is an opportunity for earlier corticosteroid administration. Most EMS agencies carry intravenous (IV) corticosteroids; yet given the challenges and low rates of EMS pediatric IV placement, oral corticosteroids (OCS) are a logical alternative. However, previous single-agency studies showed low adoption of OCS. Therefore, qualitative study of OCS implementation by EMS is warranted.Methods: This study's objective was to explore uptake and implementation of OCS for pediatric asthma treatment through semi-structured interviews and focus groups with EMS clinicians. We thematically coded and analyzed transcripts using the domains and constructs of the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators that most strongly influenced OCS implementation and adoption by EMS clinicians.Results: We conducted five focus groups with a total of ten EMS clinicians from four EMS systems: one urban region with multiple agencies that hosted two focus groups, one suburban agency, one rural agency, and a mixed rural/suburban agency. Of the 36 CFIR constructs, 31 were addressed in the interviews. Most constructs coded were in the CFIR domains of the inner setting and characteristics of individuals, indicating that EMS agency factors as well as EMS clinician characteristics were impactful for implementation. Barriers to OCS adoption included unfamiliarity and inexperience with pediatric patients and pediatric dosing, and lack of knowledge of the benefits of corticosteroids. Facilitators included friendly competition with colleagues, having a pediatric medical director, and feedback from receiving EDs on patient outcomes.Conclusion: This qualitative focus group study of OCS implementation by EMS clinicians for the treatment of pediatric asthma found many barriers and facilitators that mapped to the structure of EMS agencies and characteristics of individual EMS clinicians. To fully implement this evidence-based intervention for pediatric asthma, more education on the intervention is required, and EMS clinicians will benefit from further pediatric training.
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Affiliation(s)
- Kayla McManus
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Alexandra Cheetham
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Lauren Riney
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Jennifer Brailsford
- Center for Data Solutions, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Jennifer N Fishe
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
- Center for Data Solutions, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
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5
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Schuh S, Freedman SB, Zemek R, Plint AC, Johnson DW, Ducharme F, Gravel J, Thompson G, Curtis S, Stephens D, Coates AL, Black KJ, Beer D, Sweeney J, Rumantir M, Finkelstein Y. Association Between Intravenous Magnesium Therapy in the Emergency Department and Subsequent Hospitalization Among Pediatric Patients With Refractory Acute Asthma: Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2117542. [PMID: 34279646 PMCID: PMC8290299 DOI: 10.1001/jamanetworkopen.2021.17542] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Despite guidelines recommending administration of intravenous (IV) magnesium sulfate for refractory pediatric asthma, the number of asthma-related hospitalizations has remained stable, and IV magnesium therapy is independently associated with hospitalization. OBJECTIVE To examine the association between IV magnesium therapy administered in the emergency department (ED) and subsequent hospitalization among pediatric patients with refractory acute asthma after adjustment for patient-level variables. DESIGN, SETTING, AND PARTICIPANTS This post hoc secondary analysis of a double-blind randomized clinical trial of children with acute asthma treated from September 26, 2011, to November 19, 2019, at 7 Canadian tertiary care pediatric EDs was conducted between September and November 2020. In the randomized clinical trial, 816 otherwise healthy children aged 2 to 17 years with Pediatric Respiratory Assessment Measure (PRAM) scores of 5 points or higher after initial therapy with systemic corticosteroids and inhaled albuterol with ipratropium bromide were randomly assigned to 3 nebulized treatments of albuterol plus either magnesium sulfate or 5.5% saline placebo. EXPOSURES Intravenous magnesium sulfate therapy (40-75 mg/kg). MAIN OUTCOMES AND MEASURES The association between IV magnesium therapy in the ED and subsequent hospitalization for asthma was assessed using multivariable logistic regression analysis. Analyses were adjusted for year epoch at enrollment, receipt of IV magnesium, PRAM score after initial therapy and at ED disposition, age, sex, duration of respiratory distress, previous intensive care unit admission for asthma, hospitalizations for asthma within the past year, atopy, and receipt of oral corticosteroids within 48 hours before arrival in the ED, nebulized magnesium, and additional albuterol after inhaled magnesium or placebo, with site as a random effect. RESULTS Among the 816 participants, the median age was 5 years (interquartile range, 3-7 years), 517 (63.4%) were boys, and 364 (44.6%) were hospitalized. A total of 215 children (26.3%) received IV magnesium, and 190 (88.4%) of these children were hospitalized compared with 174 of 601 children (29.0%) who did not receive IV magnesium. Multivariable factors associated with hospitalization were IV magnesium receipt from 2011 to 2016 (odds ratio [OR], 22.67; 95% CI, 6.26-82.06; P < .001) and from 2017 to 2019 (OR, 4.19; 95% CI, 1.99-8.86; P < .001), use of additional albuterol (OR, 5.94; 95% CI, 3.52-10.01; P < .001), and increase in PRAM score at disposition (per 1-U increase: OR, 2.24; 95% CI, 1.89-2.65; P < .001). In children with a disposition PRAM score of 3 or lower, receipt of IV magnesium therapy was associated with hospitalization (OR, 8.52; 95% CI, 2.96-24.41; P < .001). CONCLUSIONS AND RELEVANCE After adjustment for patient-level characteristics, receipt of IV magnesium therapy after initial asthma treatment in the ED was associated with subsequent hospitalization. This association also existed among children with mild asthma at ED disposition. Evidence of a benefit of IV magnesium regarding hospitalization may clarify its use in the treatment of refractory pediatric asthma. TRIAL REGISTRATION ClinicalTrials.gov: NCT01429415.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Sick Kids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Section of Gastroenterology, Department of Emergency Medicine, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Roger Zemek
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Amy C. Plint
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - David W. Johnson
- Department of Pediatrics, Alberta Children’s Hospital, Calgary, Alberta, Canada
- Department of Emergency Medicine, Alberta Children’s Hospital, Calgary, Alberta, Canada
- Department of Physiology & Pharmacology, Alberta Children’s Hospital, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Francine Ducharme
- Department of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Quebec, Canada
- Department of Social and Preventive Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Jocelyn Gravel
- Department of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Quebec, Canada
- Department of Social and Preventive Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Graham Thompson
- Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Sarah Curtis
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
- Department of Emergency Medicine, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Derek Stephens
- Department of Pediatrics, Clinical Research Services, Sick Kids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Allan L. Coates
- Division of Respiratory Medicine, Sick Kids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Karen J. Black
- Division of Pediatric Emergency Medicine, British Columbia Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Darcy Beer
- Department of Pediatrics and Child Health, Division of Pediatric Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Judy Sweeney
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Maggie Rumantir
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Finkelstein
- Sick Kids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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6
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Leung JS. Paediatrics: how to manage acute asthma exacerbations. Drugs Context 2021; 10:dic-2020-12-7. [PMID: 34113386 PMCID: PMC8166724 DOI: 10.7573/dic.2020-12-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/13/2021] [Indexed: 12/11/2022] Open
Abstract
Background Asthma is the most common chronic disease of childhood and a major source of childhood health burden worldwide. These burdens are particularly marked when children experience characteristic ‘symptom flare-ups’ or acute asthma exacerbations (AAEs). AAE are associated with significant health and economic impacts, including acute Emergency Department visits, occasional hospitalizations, and rarely, death. To treat children with AAE, several medications have been studied and used. Methods We conducted a narrative review of the literature with the primary objective of understanding the evidence of their efficacy. We present this efficacy evidence in the context of a general stepwise management pathway for paediatric AAEs. This framework is developed from the combined recommendations of eight established (inter)national paediatric guidelines. Discussion Management of paediatric AAE centres around four major care goals: (1) immediate and objective assessment of AAE severity; (2) prompt and effective medical interventions to decrease respiratory distress and improve oxygenation; (3) appropriate disposition of patient; and (4) safe discharge plans. Several medications are currently recommended with varying efficacies, including heliox, systemic corticosteroids, first-line bronchodilators (salbutamol/albuterol), adjunctive bronchodilators (ipratropium bromide, magnesium sulfate) and second-line bronchodilators (aminophylline, i.v. salbutamol, i.v. terbutaline, epinephrine, ketamine). Care of children with AAE is further enhanced using clinical severity scoring, pathway-driven care and after-event discharge planning. Conclusions AAEs in children are primarily managed by medications supported by a growing body of literature. Continued efforts to study the efficacy of second-line bronchodilators, integrate AAE management with long-term asthma control and provide fair/equitable care are required.
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Affiliation(s)
- James S Leung
- McMaster University, Faculty of Health Sciences, Department of Pediatrics, McMaster Children's Hospital, Hamilton, ON, Canada
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7
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Wallace A, Sinclair O, Shepherd M, Neutze J, Trenholme A, Tan E, Brabyn C, Bonisch M, Grey N, Johnson DW, McNamara D, Thompson JMD, Asher I, Dalziel SR. Impact of oral corticosteroids on respiratory outcomes in acute preschool wheeze: a randomised clinical trial. Arch Dis Child 2021; 106:339-344. [PMID: 33067310 DOI: 10.1136/archdischild-2020-318971] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 07/01/2020] [Accepted: 08/25/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine if administration of oral prednisolone to preschool children with acute wheeze alters respiratory outcomes. DESIGN Double-blind, randomised, placebo-controlled equivalence trial. SETTING Three hospitals in New Zealand. PATIENTS 477 children aged 24-59 months with acute wheeze associated with respiratory illness. INTERVENTIONS 2 mg/kg (maximum 40 mg) oral prednisolone or similar placebo, once daily for 3 days. MAIN OUTCOME MEASURES Primary outcome was change in Preschool Respiratory Assessment Measure (PRAM) score 24 hours after intervention. Secondary outcomes included PRAM score at 4 hours, length of emergency department and inpatient stays, admission and representation rates, time to return to normal activities and use of additional oral prednisolone or intravenous medications. Analysis was by intention-to-treat. RESULTS There was no difference between groups for change in PRAM score at 24 hours (difference between means -0.39, 95% CI -0.84 to 0.06, p=0.09). Absolute PRAM score was lower in the prednisolone group at 4 hours (median (IQR) 1 (0-2) vs 2 (0-3), p=0.01) and 24 hours (0 (0-1) vs 0 (0-1), p=0.01), when symptoms had resolved for most children regardless of initial treatment. Admission rate, requirement for additional oral prednisolone and use of intravenous medication were lower in the prednisolone group, although there were no differences between groups for time taken to return to normal activities or rates of representation within 7 days. CONCLUSION Oral prednisolone does not alter respiratory outcomes at 24 hours or beyond in preschool children presenting with acute wheeze.
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Affiliation(s)
- Alexandra Wallace
- Department of Paediatrics, Waikato Hospital, Hamilton, New Zealand.,Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Owen Sinclair
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Paediatric Department, Waitakere Hospital, Auckland, New Zealand
| | - Michael Shepherd
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Children's Emergency Department, Starship Children's Health, Auckland, New Zealand
| | - Jocelyn Neutze
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Kidz First, Middlemore Hospital, Auckland, New Zealand
| | - Adrian Trenholme
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Kidz First, Middlemore Hospital, Auckland, New Zealand
| | - Eunicia Tan
- Emergency Department, Middlemore Hospital, Auckland, New Zealand.,Department of Surgery, The University of Auckland, Auckland, New Zealand
| | | | - Megan Bonisch
- Children's Emergency Department, Starship Children's Health, Auckland, New Zealand
| | - Naomi Grey
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - David W Johnson
- Departments of Paediatrics, Emergency Medicine, and Pharmacology and Physiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David McNamara
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Respiratory Medicine, Starship Children's Health, Auckland, New Zealand
| | - John M D Thompson
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Innes Asher
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Respiratory Medicine, Starship Children's Health, Auckland, New Zealand
| | - Stuart R Dalziel
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand .,Children's Emergency Department, Starship Children's Health, Auckland, New Zealand.,Department of Surgery, The University of Auckland, Auckland, New Zealand
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8
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Neves VC, Souza JDOD, Koliski A, Miranda BS, Silva DCCE. High flow nasal cannula in asthmatic children with suspected COVID-19. FISIOTERAPIA EM MOVIMENTO 2021. [DOI: 10.1590/fm.2021.34302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Introduction: The use of a high-flow nasal cannula as an alternative treatment for acute respiratory failure can reduce the need for invasive mechanical ventilation and the duration of hospital stays. Objective: The present study aimed to describe the use of a high-flow nasal cannula in pediatric asthmatic patients with acute respiratory failure and suspected COVID-19. Methods: To carry out this research, data were collected from medical records, including three patients with asthma diagnoses. The variables studied were: personal data (name, age in months, sex, weight, and color), clinical data (physical examination, PRAM score, respiratory rate, heart rate, and peripheral oxygen saturation), diagnosis, history of the current disease, chest, and laboratory radiography (arterial blood gases and reverse-transcriptase polymerase chain reaction). Clinical data were compared before and after using a high-flow nasal cannula. Results: After the application of the therapy, a gradual improvement in heart, respiratory rate, PaO2/FiO2 ratio, and the Pediatric Respiratory Assessment Measure score was observed. Conclusion: The simple and quick use of a high-flow nasal cannula in pediatric patients with asthma can be safe and efficient in improving their respiratory condition and reducing the need for intubation.
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9
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Rehouma H, Noumeir R, Essouri S, Jouvet P. Advancements in Methods and Camera-Based Sensors for the Quantification of Respiration. SENSORS (BASEL, SWITZERLAND) 2020; 20:E7252. [PMID: 33348827 PMCID: PMC7766256 DOI: 10.3390/s20247252] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/09/2020] [Accepted: 12/15/2020] [Indexed: 01/22/2023]
Abstract
Assessment of respiratory function allows early detection of potential disorders in the respiratory system and provides useful information for medical management. There is a wide range of applications for breathing assessment, from measurement systems in a clinical environment to applications involving athletes. Many studies on pulmonary function testing systems and breath monitoring have been conducted over the past few decades, and their results have the potential to broadly impact clinical practice. However, most of these works require physical contact with the patient to produce accurate and reliable measures of the respiratory function. There is still a significant shortcoming of non-contact measuring systems in their ability to fit into the clinical environment. The purpose of this paper is to provide a review of the current advances and systems in respiratory function assessment, particularly camera-based systems. A classification of the applicable research works is presented according to their techniques and recorded/quantified respiration parameters. In addition, the current solutions are discussed with regards to their direct applicability in different settings, such as clinical or home settings, highlighting their specific strengths and limitations in the different environments.
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Affiliation(s)
- Haythem Rehouma
- École de Technologie Supérieure, Montreal, QC H3T 1C5, Canada;
| | - Rita Noumeir
- École de Technologie Supérieure, Montreal, QC H3T 1C5, Canada;
| | - Sandrine Essouri
- CHU Sainte-Justine, Montreal, QC H3T 1C5, Canada; (S.E.); (P.J.)
| | - Philippe Jouvet
- CHU Sainte-Justine, Montreal, QC H3T 1C5, Canada; (S.E.); (P.J.)
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10
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Abecassis L, Gaffin JM, Forbes PW, Schenkel SR, McBride S, DeGrazia M. Validation of the Hospital Asthma Severity Score (HASS) in children ages 2-18 years old. J Asthma 2020; 59:315-324. [PMID: 33198536 DOI: 10.1080/02770903.2020.1852414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The Hospital Asthma Severity Score (HASS) was developed to communicate inpatient asthma severity between providers. The purpose of this prospective study was to validate the HASS against the Pediatric Respiratory Assessment Measure (PRAM) and spirometry for assessment of inpatient asthma exacerbation severity in patients 2-18 years old, at a single point-in-time. METHODS This study was registered with clinicaltrials.gov (NCT02782065). Children admitted to a tertiary care, free-standing children's hospital were assessed for asthma severity using the HASS, PRAM, and pulmonary function by spirometry. Inter-rater agreement of HASS and PRAM scores was assessed between two blinded clinician raters. Spirometry results were obtained by a certified pulmonary laboratory technician and correlated with HASS and PRAM scores. RESULTS The sample included 58 subjects. Allowing for a one-point difference in continuous HASS and PRAM scores, inter-rater agreement was 79% for the HASS and 60% for the PRAM. When the scores were categorized as mild, moderate, and severe, inter-rater agreement was 62% for the HASS and 93% for the PRAM (p < .0001). Additionally, intra-rater agreement between HASS and PRAM severity categories was 71% for Rater 1 and 64% for Rater 2. A weak correlation was noted between both the HASS and FEV1 (r = -0.31; p = 0.11), and PRAM and FEV1 (r = -0.30; p = 0.11) for the 29 subjects with acceptable spirometry results. CONCLUSIONS The HASS and PRAM have acceptable inter-rater and intra-rater agreement. These results support validation of the HASS for managing hospitalized patients during asthma exacerbations.
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Affiliation(s)
- Leah Abecassis
- Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, MA, USA
| | - Jonathan M Gaffin
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Peter W Forbes
- Clinical Research Center, Boston Children's Hospital, Boston, MA, USA
| | - Sara R Schenkel
- Division of Pediatric Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah McBride
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Michele DeGrazia
- Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
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11
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Lee MO, Sivasankar S, Pokrajac N, Smith C, Lumba‐Brown A. Emergency department treatment of asthma in children: A review. J Am Coll Emerg Physicians Open 2020; 1:1552-1561. [PMID: 33392563 PMCID: PMC7771822 DOI: 10.1002/emp2.12224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
Asthma is the most common chronic illness in children, with >700,000 emergency department (ED) visits each year. Asthma is a respiratory disease characterized by a combination of airway inflammation, bronchoconstriction, bronchial hyperresponsiveness, and variable outflow obstruction, with clinical presentations ranging from mild to life-threatening. Standardized ED treatment can improve patient outcomes, including fewer hospital admissions. Informed by the most recent guidelines, this review focuses on the optimal approach to diagnosis and treatment of children with acute asthma exacerbations who present to the ED.
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Affiliation(s)
- Moon O. Lee
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Shyam Sivasankar
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Nicholas Pokrajac
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Cherrelle Smith
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Angela Lumba‐Brown
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
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12
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Schuh S, Sweeney J, Rumantir M, Coates AL, Willan AR, Stephens D, Atenafu EG, Finkelstein Y, Thompson G, Zemek R, Plint AC, Gravel J, Ducharme FM, Johnson DW, Black K, Curtis S, Beer D, Klassen TP, Nicksy D, Freedman SB. Effect of Nebulized Magnesium vs Placebo Added to Albuterol on Hospitalization Among Children With Refractory Acute Asthma Treated in the Emergency Department: A Randomized Clinical Trial. JAMA 2020; 324:2038-2047. [PMID: 33231663 PMCID: PMC7686869 DOI: 10.1001/jama.2020.19839] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE While intravenous magnesium decreases hospitalizations in refractory pediatric acute asthma, it is variably used because of invasiveness and safety concerns. The benefit of nebulized magnesium to prevent hospitalization is unknown. OBJECTIVE To evaluate the effectiveness of nebulized magnesium in children with acute asthma remaining in moderate or severe respiratory distress after initial therapy. DESIGN, SETTING, AND PARTICIPANTS A randomized double-blind parallel-group clinical trial from September 26, 2011, to November 19, 2019, in 7 tertiary-care pediatric emergency departments in Canada. The participants were otherwise healthy children aged 2 to 17 years with moderate to severe asthma defined by a Pediatric Respiratory Assessment Measure (PRAM) score of 5 or greater (on a 12-point scale) after a 1-hour treatment with an oral corticosteroid and 3 inhaled albuterol and ipratropium treatments. Of 5846 screened patients, 4332 were excluded for criteria, 273 declined participation, 423 otherwise excluded, 818 randomized, and 816 analyzed. INTERVENTIONS Participants were randomized to 3 nebulized albuterol treatments with either magnesium sulfate (n = 410) or 5.5% saline placebo (n = 408). MAIN OUTCOMES AND MEASURES The primary outcome was hospitalization for asthma within 24 hours. Secondary outcomes included PRAM score; respiratory rate; oxygen saturation at 60, 120, 180, and 240 minutes; blood pressure at 20, 40, 60, 120, 180, and 240 minutes; and albuterol treatments within 240 minutes. RESULTS Among 818 randomized patients (median age, 5 years; 63% males), 816 completed the trial (409 received magnesium; 407, placebo). A total of 178 of the 409 children who received magnesium (43.5%) were hospitalized vs 194 of the 407 who received placebo (47.7%) (difference, -4.2%; absolute risk difference 95% [exact] CI, -11% to 2.8%]; P = .26). There were no significant between-group differences in changes from baseline to 240 minutes in PRAM score (difference of changes, 0.14 points [95% CI, -0.23 to 0.50]; P = .46); respiratory rate (0.17 breaths/min [95% CI, -1.32 to 1.67]; P = .82); oxygen saturation (-0.04% [95% CI, -0.53% to 0.46%]; P = .88); systolic blood pressure (0.78 mm Hg [95% CI, -1.48 to 3.03]; P = .50); or mean number of additional albuterol treatments (magnesium: 1.49, placebo: 1.59; risk ratio, 0.94 [95% CI, 0.79 to 1.11]; P = .47). Nausea/vomiting or sore throat/nose occurred in 17 of the 409 children who received magnesium (4%) and 5 of the 407 who received placebo (1%). CONCLUSIONS AND RELEVANCE Among children with refractory acute asthma in the emergency department, nebulized magnesium with albuterol, compared with placebo with albuterol, did not significantly decrease the hospitalization rate for asthma within 24 hours. The findings do not support use of nebulized magnesium with albuterol among children with refractory acute asthma. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01429415.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Judy Sweeney
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Maggie Rumantir
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Allan L. Coates
- Division of Respiratory Medicine, Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrew R. Willan
- Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Derek Stephens
- Research Institute, Clinical Research Services, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eshetu G. Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Finkelstein
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Graham Thompson
- Departments of Pediatrics and Emergency Medicine, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Roger Zemek
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Amy C. Plint
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Jocelyn Gravel
- Department of Pediatric Emergency Medicine, CHU Sainte-Justine, Montréal, Quebec, Canada
- Department of Pediatrics and of Social and Preventive Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Francine M. Ducharme
- Department of Pediatric Emergency Medicine, CHU Sainte-Justine, Montréal, Quebec, Canada
- Department of Pediatrics and of Social and Preventive Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - David W. Johnson
- Departments of Pediatrics, Emergency Medicine, and Physiology & Pharmacology, Alberta Children’s Hospital, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karen Black
- Division of Pediatric Emergency Medicine, British Columbia Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah Curtis
- Departments of Pediatrics and Emergency Medicine, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Darcy Beer
- Pediatrics/Pediatric Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Terry P. Klassen
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
- Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Darcy Nicksy
- Pharmacy Department, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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13
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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.
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14
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Lejeune S, Pichavant M, Engelmann I, Béghin L, Drumez E, Le Rouzic O, Dessein R, Rogeau S, Beke T, Kervoaze G, Delvart C, Ducoin H, Pouessel G, Le Mée A, Boileau S, Roussel J, Bonnel C, Mordacq C, Thumerelle C, Gosset P, Deschildre A. Severe preschool asthmatics have altered cytokine and anti-viral responses during exacerbation. Pediatr Allergy Immunol 2020; 31:651-661. [PMID: 32352598 DOI: 10.1111/pai.13268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/20/2020] [Accepted: 04/20/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Preschool asthma/recurrent wheeze is a heterogeneous condition. Different clinical phenotypes have been described, including episodic viral wheeze (EVW), severe intermittent wheeze (SIW), and multiple-trigger wheeze (MTW). OBJECTIVE To compare clinical, viral, and inflammatory/immune profiling at exacerbation between MTW, SIW, and EVW phenotypes. METHODS Multicenter, prospective, observational cohort (VIRASTHMA-2). Children (1-5 years) with preschool asthma were enrolled during hospitalization for a severe exacerbation. History and anamnestic data, plasma, and nasal samples were collected at exacerbation (T1) and at steady state, 8 weeks later (T2), and sputum samples were collected at T1. RESULTS A total of 147 children were enrolled, 37 (25%) had SIW, 18 (12.2%) EVW, and 92 (63%) MTW. They were atopic (47%), exposed to mold (22%) and cigarette smoke (50%), and prone to exacerbations (≥2 in the previous year in 70%). At exacerbation, at least one virus was isolated in 94% and rhinovirus in 75%, with no difference between phenotypes. Children with MTW and SIW phenotypes displayed lower plasma concentrations of IFN-γ (P = .002), IL-5 (P = .020), TNF-α (P = .038), IL-10 (P = .002), IFN-β (P = .036), and CXCL10 (P = .006) and lower levels of IFN-γ (P = .047) in sputum at exacerbation than children with EVW. At T2, they also displayed lower plasma levels of IFN-γ (P = .045) and CXCL10 (P = .013). CONCLUSION Among preschool asthmatic children, MTW and SIW, prone to exacerbations, display lower systemic levels of Th1, Th2 cytokines, pro- and anti-inflammatory cytokines, and antiviral responses during severe virus-induced exacerbation.
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Affiliation(s)
- Stéphanie Lejeune
- Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, CHU Lille, Univ. Lille, Lille cedex, France.,INSERM Unit 1019, CNRS UMR 9017, Center for Infection and Immunity of Lille, Institut Pasteur de Lille, CHU Lille, Univ. Lille, Lille cedex, France
| | - Muriel Pichavant
- INSERM Unit 1019, CNRS UMR 9017, Center for Infection and Immunity of Lille, Institut Pasteur de Lille, CHU Lille, Univ. Lille, Lille cedex, France
| | - Ilka Engelmann
- Virology Laboratory, EA3610, Institute of Microbiology, CHU Lille, Univ. Lille, Lille cedex, France
| | - Laurent Béghin
- LIRIC UMR 995 Inserm, Clinical Investigation Center, CIC-1403-Inserm-CHU, CHU Lille, Univ. Lille, Lille, France
| | - Elodie Drumez
- ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, CHU Lille, Univ. Lille, Lille, France.,Department of Biostatistics, CHU Lille, Lille, France
| | - Olivier Le Rouzic
- INSERM Unit 1019, CNRS UMR 9017, Center for Infection and Immunity of Lille, Institut Pasteur de Lille, CHU Lille, Univ. Lille, Lille cedex, France
| | - Rodrigue Dessein
- INSERM Unit 1019, CNRS UMR 9017, Center for Infection and Immunity of Lille, Institut Pasteur de Lille, CHU Lille, Univ. Lille, Lille cedex, France.,Bacteriology Department, Institute of Microbiology, CHU Lille, Univ. Lille, Lille cedex, France
| | - Stéphanie Rogeau
- Institute of Immunology, CHU Lille, Univ. Lille, Lille, Lille cedex, France
| | - Timothée Beke
- INSERM Unit 1019, CNRS UMR 9017, Center for Infection and Immunity of Lille, Institut Pasteur de Lille, CHU Lille, Univ. Lille, Lille cedex, France
| | - Gwenola Kervoaze
- INSERM Unit 1019, CNRS UMR 9017, Center for Infection and Immunity of Lille, Institut Pasteur de Lille, CHU Lille, Univ. Lille, Lille cedex, France
| | | | - Héloïse Ducoin
- Pediatric Department, CH Lens E. Schaffner, Lens cedex, France
| | | | | | | | | | - Cécile Bonnel
- Pediatric Department, CH Bethune, Bethune cedex, France
| | - Clémence Mordacq
- Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, CHU Lille, Univ. Lille, Lille cedex, France.,INSERM Unit 1019, CNRS UMR 9017, Center for Infection and Immunity of Lille, Institut Pasteur de Lille, CHU Lille, Univ. Lille, Lille cedex, France
| | - Caroline Thumerelle
- Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, CHU Lille, Univ. Lille, Lille cedex, France.,INSERM Unit 1019, CNRS UMR 9017, Center for Infection and Immunity of Lille, Institut Pasteur de Lille, CHU Lille, Univ. Lille, Lille cedex, France
| | - Philippe Gosset
- INSERM Unit 1019, CNRS UMR 9017, Center for Infection and Immunity of Lille, Institut Pasteur de Lille, CHU Lille, Univ. Lille, Lille cedex, France
| | - Antoine Deschildre
- Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, CHU Lille, Univ. Lille, Lille cedex, France.,INSERM Unit 1019, CNRS UMR 9017, Center for Infection and Immunity of Lille, Institut Pasteur de Lille, CHU Lille, Univ. Lille, Lille cedex, France
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Melendez E, Dwyer D, Donelly D, Currier D, Nachreiner D, Miller DM, Hurlbut J, Pepin MJ, Agus MSD, Wong J. Standardized Protocol Is Associated With a Decrease in Continuous Albuterol Use and Length of Stay in Critical Status Asthmaticus. Pediatr Crit Care Med 2020; 21:451-460. [PMID: 32084098 DOI: 10.1097/pcc.0000000000002239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The primary aim of this study was to reduce duration of continuous albuterol and hospital length of stay in critically ill children with severe status asthmaticus. DESIGN Observational prospective study from September 2012 to May 2016. SETTING Medicine ICU and intermediate care unit. PATIENTS Children greater than 2 years old with admission diagnosis of status asthmaticus admitted on continuous albuterol and managed via a standardized protocol. INTERVENTIONS The protocol was an iterative algorithm for escalation and weaning of therapy. The algorithm underwent three revisions. Iteration 1 concentrated on reducing duration on continuous albuterol; iteration 2 concentrated on reducing hospital length of stay; and iteration 3 concentrated on reducing helium-oxygen delivered continuous albuterol. Balancing measures included adverse events and readmissions. MEASUREMENTS AND RESULTS Three-hundred eighty-five patients were treated as follows: 123, 138, and 124 in iterations 1, 2, and 3, respectively. Baseline data was gathered from an additional 150 patients prior to protocol implementation. There was no difference in median age (6 vs 8 vs 7 vs 7 yr; p = 0.130), asthma severity score (9 vs 9 vs 9 vs 9; p = 0.073), or female gender (42% vs 41% vs 43% vs 48%; p = 0.757). Using statistical process control charts, the mean duration on continuous albuterol decreased from 24.9 to 17.5 hours and the mean hospital length of stay decreased from 76 to 49 hours. There was no difference in adverse events (0% vs 1% vs 4% vs 0%; p = 0.054) nor in readmissions (0% vs 0% vs 1% vs 2%; p = 0.254). CONCLUSIONS Implementation of a quality improvement protocol in critically ill patients with status asthmaticus was associated with a decrease in continuous albuterol duration and hospital length of stay.
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Affiliation(s)
- Elliot Melendez
- Division of Medicine Critical Care, Boston Children's Hospital, Harvard Medical School Boston, MA.,Division of Pediatric Critical Care, Department of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Danielle Dwyer
- Division of Medicine Critical Care, Boston Children's Hospital, Harvard Medical School Boston, MA
| | - Daria Donelly
- Department of Respiratory Care, Boston Children's Hospital, Boston, MA
| | - Denise Currier
- Division of Medicine Critical Care, Boston Children's Hospital, Harvard Medical School Boston, MA
| | - Daniel Nachreiner
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA
| | - D Marlowe Miller
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA
| | - Julie Hurlbut
- Division of Medicine Critical Care, Boston Children's Hospital, Harvard Medical School Boston, MA
| | - Michael J Pepin
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA
| | - Michael S D Agus
- Division of Medicine Critical Care, Boston Children's Hospital, Harvard Medical School Boston, MA
| | - Jackson Wong
- Division of Medicine Critical Care, Boston Children's Hospital, Harvard Medical School Boston, MA
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16
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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.
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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
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Fisher JD, Sakaria RP, Siddiqui KN, Ivey KJ, Bali L, Burnette K. Initial ED oxygen saturation ≤90% increases the risk of a complicated hospital course in pediatric asthmatics requiring admission. Am J Emerg Med 2019; 37:1743-1745. [PMID: 31230924 DOI: 10.1016/j.ajem.2019.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 05/18/2019] [Accepted: 06/13/2019] [Indexed: 11/15/2022] Open
Abstract
Emergency physicians are responsible for admitting children with asthma who do not respond to initial therapy. We examined the hypothesis that an initial room air pulse oximetry ≤90% elevates the risk of a complicated hospital course in children who require admission with acute asthma. METHODS Charts of all patients ages 2 years-17 years admitted for asthma from January 2017 to December 2017 were reviewed. An explicit chart review was performed by trained data extractors using a standardized form. RESULTS A total of 244 children meeting inclusion criteria were admitted for asthma from the ED during the study period. All patients had an initial room air pulse oximetry documented. Sixty-five were admitted to PICU status (27%), and 179 (73%) were admitted to floor status. The relative risk of a complicated course in those patients presenting with a saturation of ≤90% was 11.3 (95% CI 3.9-32.6). The mean initial pulse oximetry on patients with a complicated course was 85% versus 93% for those without a complicated course (p < 0.005). CONCLUSION Our data suggest that in pediatric asthmatics that require admission from the ED, those with pulse oximetry readings less than or equal to 90% on presentation are at higher risk of a complicated hospital course.
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Affiliation(s)
- Jay D Fisher
- UNLV School of Medicine, Department of Emergency Medicine, United States of America.
| | - Rishika P Sakaria
- UNLV School of Medicine, Department of Pediatric, United States of America
| | - Korrina N Siddiqui
- UNLV School of Medicine, Department of Emergency Medicine, United States of America
| | - Kristopher J Ivey
- UNLV School of Medicine, Department of Emergency Medicine, United States of America
| | - Lauren Bali
- UNLV School of Medicine, Department of Emergency Medicine, United States of America
| | - Kreg Burnette
- UNLV School of Medicine, Department of Emergency Medicine, United States of America
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Al-Shamrani A, Al-Harbi AS, Bagais K, Alenazi A, Alqwaiee M. Management of asthma exacerbation in the emergency departments. Int J Pediatr Adolesc Med 2019; 6:61-67. [PMID: 31388549 PMCID: PMC6676463 DOI: 10.1016/j.ijpam.2019.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | - Adel S Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Saudi Arabia
| | - Khalid Bagais
- Department of Pediatrics, Prince Sultan Military Medical City, Saudi Arabia
| | - Ayed Alenazi
- Department of Pediatrics, Prince Sultan Military Medical City, Saudi Arabia
| | - Mansour Alqwaiee
- Department of Pediatrics, Prince Sultan Military Medical City, Saudi Arabia
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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
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20
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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.
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21
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Al-Moamary MS, Alhaider SA, Alangari AA, Al Ghobain MO, Zeitouni MO, Idrees MM, Alanazi AF, Al-Harbi AS, Yousef AA, Alorainy HS, Al-Hajjaj MS. The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2019; 14:3-48. [PMID: 30745934 PMCID: PMC6341863 DOI: 10.4103/atm.atm_327_18] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.
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Affiliation(s)
- Mohamed S Al-Moamary
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullah A Alangari
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed O Al Ghobain
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed O Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Majdy M Idrees
- Respiratory Division, Department of Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah F Alanazi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Adel S Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hassan S Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed S Al-Hajjaj
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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22
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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.
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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
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23
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Judge P, Tabeshi R, Yao RJ, Meckler G, Doan Q. Use of a standardized asthma severity score to determine emergency department disposition for paediatric asthma: A cohort study. Paediatr Child Health 2018; 24:227-233. [PMID: 31239811 DOI: 10.1093/pch/pxy125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/28/2018] [Indexed: 11/14/2022] Open
Abstract
Background We recently introduced a clinical practice pathway for the management of asthma that uses the Pediatric Respiratory Assessment Measure (PRAM) to guide emergency department (ED) treatment and disposition. The pathway recommends discharge for patients who achieve improvement to PRAM <4 at 1 hour after the last bronchodilator. We evaluated practice variation and patient outcomes associated with PRAM-directed disposition recommendations. Methods We conducted a retrospective cohort study of children aged 2 to 17 years treated for moderate asthma (PRAM score 4-7) using our asthma clinical pathway. We measured 1) the proportion of children discharged per pathway criteria who returned to our ED within 24 hours and 2) the proportion of children observed beyond the pathway discharge criteria who deteriorated (PRAM ≥4). Results We analyzed 385 patient records from September 2013 to February 2015. Among 145 (37.7%) patients discharged per pathway criteria, 4 (4/145; 2.8%) returned within 24 hours. The remaining 240 (62.2%) were observed beyond the pathway discharge criteria; 76/240 (31.7%) had a subsequent deterioration (PRAM score ≥ 4) and 25/240 (10.4%) were hospitalized. Of those who deteriorated, 46/76 (60.5%) worsened within the first additional hour of observation. Conclusion We observed significant deviation from our PRAM-directed pathway discharge criteria and that a significant proportion of observed patients experienced clinical deterioration beyond the first hour of observation. We recommend observing children with moderate asthma for 2 or 3 hours from last bronchodilator therapy if PRAM < 4 is maintained, to capture the majority (97.7% or 99.7%) of patients who require further intervention and hospitalization.
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Affiliation(s)
- Pavan Judge
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia.,Department of Pediatrics, Division of Emergency Medicine, British Columbia Children's Hospital, Vancouver, British Columbia
| | - Raymond Tabeshi
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Ren Jie Yao
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Garth Meckler
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia.,Department of Pediatrics, Division of Emergency Medicine, British Columbia Children's Hospital, Vancouver, British Columbia
| | - Quynh Doan
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia.,Department of Pediatrics, Division of Emergency Medicine, British Columbia Children's Hospital, Vancouver, British Columbia
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Abstract
Asthma is the most common respiratory disorder in Canada. Despite significant improvement in the diagnosis and management of this disorder, the majority of Canadians with asthma remain poorly controlled. In most patients, however, control can be achieved through the use of avoidance measures and appropriate pharmacological interventions. Inhaled corticosteroids (ICS) represent the standard of care for the majority of patients. Combination ICS/long-acting beta2-agonist inhalers are preferred for most adults who fail to achieve control with ICS therapy. Biologic therapies targeting immunoglobulin E or interleukin-5 are recent additions to the asthma treatment armamentarium and may be useful in select cases of difficult to control asthma. Allergen-specific immunotherapy represents a potentially disease-modifying therapy for many patients with asthma, but should only be prescribed by physicians with appropriate training in allergy. In addition to avoidance measures and pharmacotherapy, essential components of asthma management include: regular monitoring of asthma control using objective testing measures such as spirometry, whenever feasible; creation of written asthma action plans; assessing barriers to treatment and adherence to therapy; and reviewing inhaler device technique. This article provides a review of current literature and guidelines for the appropriate diagnosis and management of asthma in adults and children.
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Affiliation(s)
| | | | | | | | - Harold Kim
- 1McMaster University, Hamilton, ON Canada.,3Western University, London, ON Canada
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25
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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]
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26
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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]
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27
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Patel SJ, Arnold DH, Topoz I, Sills MR. Literature Review: Prediction Modeling of Emergency Department Disposition Decisions for Children with Acute Asthma Exacerbations. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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28
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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.
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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
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29
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Arnold DH, Johnson DP, Yang CL, Hartert TV. Forced expiratory values in 1 second corresponding to Pediatric Respiratory Assessment Measure and Acute Asthma Intensity Research Score values during pediatric acute asthma exacerbations. Ann Allergy Asthma Immunol 2017; 119:561-562. [PMID: 29107465 DOI: 10.1016/j.anai.2017.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/04/2017] [Accepted: 09/07/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Donald H Arnold
- Division of Emergency Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; The Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - David P Johnson
- Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Connie L Yang
- Division of Respiratory Medicine, Department of Pediatrics, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Tina V Hartert
- The Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee; Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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30
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Justicia-Grande AJ, Pardo Seco J, Rivero Calle I, Martinón-Torres F. Clinical respiratory scales: which one should we use? Expert Rev Respir Med 2017; 11:925-943. [PMID: 28974118 DOI: 10.1080/17476348.2017.1387052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION There are countless clinical respiratory scales for acute dyspnoea. Most healthcare professionals choose one based on previous personal experience or following local practice, unaware of the implications of their choice. The lack of critical comparisons between those different tools has been a widespread problem that only recently has begun to be addressed via score validation studies. Here we try to assess and compare the quality criteria of measurement properties of acute dyspnoea scores. Areas covered: A literature review was conducted by searching the PubMed database. Forty-five documents were deemed eligible as they reported the use or building of clinical scales, using at least two parameters, and applied these to an acute episode of respiratory dyspnoea. Our primary focus was the description of the validity, reliability and utility of 41 suitable scoring instruments. Differences in sample selection, study design, rater profiles and potential methodological shortcomings were also addressed. Expert commentary: All acute dyspnoea scores lack complete validation. In particular, the areas of measurement error and interpretability have not been addressed correctly by any of the tools reviewed. Frequent modification of pre-existing scores (in items composition and/or name), differences in study design and discrepancies in reviewed sources also hinder the search for an adequate tool.
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Affiliation(s)
- Antonio José Justicia-Grande
- a Translational Pediatrics and Infectious Diseases, Department of Pediatrics , Hospital Clínico Universitario de Santiago de Compostela , A Coruña , Spain.,b Healthcare Research Institute , Instituto de Investigación Sanitaria de Santiago, GENVIP group , Santiago de Compostela, A Coruña , Spain
| | - Jacobo Pardo Seco
- b Healthcare Research Institute , Instituto de Investigación Sanitaria de Santiago, GENVIP group , Santiago de Compostela, A Coruña , Spain
| | - Irene Rivero Calle
- a Translational Pediatrics and Infectious Diseases, Department of Pediatrics , Hospital Clínico Universitario de Santiago de Compostela , A Coruña , Spain.,b Healthcare Research Institute , Instituto de Investigación Sanitaria de Santiago, GENVIP group , Santiago de Compostela, A Coruña , Spain
| | - Federico Martinón-Torres
- a Translational Pediatrics and Infectious Diseases, Department of Pediatrics , Hospital Clínico Universitario de Santiago de Compostela , A Coruña , Spain.,b Healthcare Research Institute , Instituto de Investigación Sanitaria de Santiago, GENVIP group , Santiago de Compostela, A Coruña , Spain
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31
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Lambert KA, Prendergast LA, Dharmage SC, Tang M, O'Sullivan M, Tran T, Druce J, Bardin P, Abramson MJ, Erbas B. The role of human rhinovirus (HRV) species on asthma exacerbation severity in children and adolescents. J Asthma 2017; 55:596-602. [PMID: 29020463 DOI: 10.1080/02770903.2017.1362425] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE It is recognized that human rhinovirus (HRV) infection is an important factor in asthma exacerbations requiring hospitalization in children. However, previous studies have disagreed on the differential impact of various HRV species. We sought to assess the impact of HRV species on the severity of asthma exacerbations in children and adolescents. We also examined whether the effect of HRV species on severity was modified by age and gender. METHODS Virus strain was determined for 113 children with HRV detectable at the time of admission for asthma exacerbation. Patient characteristics were collected on admission and exacerbation severity was scored using several validated scales. RESULTS HRV species by itself was not associated with moderate/severe vs. mild exacerbations. Boys with HRV-C infections were more likely (OR: 3.7, 95% CI: 1.2-13.4) to have a moderate/severe exacerbation than girls with HRV-C (p = 0.04 for interaction term). Higher odds were observed in younger boys (3 years old: OR: 9.1, 95% CI: 1.8-47.1 vs 5 years old: OR: 3.3, 95% CI: 0.9-11.8 vs 7 years old: OR: 1.2, 95% CI: 0.2-6.6). In contrast, children with HRV-C infection and sensitized to pollen during the pollen season were less likely to have moderate/severe exacerbations (p = 0.01 for the interaction term). CONCLUSION Acute asthma exacerbations are more likely to be moderate/severe in boys under 5 years of age who had HRV-C infection on admission. The opposite was found in children with sensitization to pollen during pollen season.
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Affiliation(s)
- Katrina A Lambert
- a School of Psychology and Public Health , La Trobe University , Victoria , Melbourne , Australia
| | - Luke A Prendergast
- b Department of Mathematics and Statistics , La Trobe University , Victoria , Melbourne , Australia
| | - Shyamali C Dharmage
- c Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health , The University of Melbourne , Victoria , Melbourne , Australia
| | - Mimi Tang
- d Department of Paediatrics , The University of Melbourne , Victoria , Melbourne , Australia.,e Murdoch Children's Research Institute , The Royal Children's Hospital , Victoria , Melbourne , Australia
| | - Molly O'Sullivan
- e Murdoch Children's Research Institute , The Royal Children's Hospital , Victoria , Melbourne , Australia
| | - Thomas Tran
- f Victorian Infectious Diseases Reference Laboratory, The Doherty Institute , Victoria , Melbourne , Australia
| | - Julian Druce
- f Victorian Infectious Diseases Reference Laboratory, The Doherty Institute , Victoria , Melbourne , Australia
| | - Philip Bardin
- g Faculty of Medicine, Nursing and Health Sciences , Monash University and Hospital , Victoria , Melbourne , Australia
| | - Michael J Abramson
- h School of Public Health and Preventive Medicine , Monash University , Victoria , Melbourne , Australia
| | - Bircan Erbas
- a School of Psychology and Public Health , La Trobe University , Victoria , Melbourne , Australia
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32
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Johnson MD, Nkoy FL, Sheng X, Greene T, Stone BL, Garvin J. Direct concurrent comparison of multiple pediatric acute asthma scoring instruments. J Asthma 2017; 54:741-753. [PMID: 27831833 PMCID: PMC5425314 DOI: 10.1080/02770903.2016.1258081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Appropriate delivery of Emergency Department (ED) treatment to children with acute asthma requires clinician assessment of acute asthma severity. Various clinical scoring instruments exist to standardize assessment of acute asthma severity in the ED, but their selection remains arbitrary due to few published direct comparisons of their properties. Our objective was to test the feasibility of directly comparing properties of multiple scoring instruments in a pediatric ED. METHODS Using a novel approach supported by a composite data collection form, clinicians categorized elements of five scoring instruments before and after initial treatment for 48 patients 2-18 years of age with acute asthma seen at the ED of a tertiary care pediatric hospital ED from August to December 2014. Scoring instruments were compared for inter-rater reliability between clinician types and their ability to predict hospitalization. RESULTS Inter-rater reliability between clinician types was not different between instruments at any point and was lower (weighted kappa range 0.21-0.55) than values reported elsewhere. Predictive ability of most instruments for hospitalization was higher after treatment than before treatment (p < 0.05) and may vary between instruments after treatment (p = 0.054). CONCLUSIONS We demonstrate the feasibility of comparing multiple clinical scoring instruments simultaneously in ED clinical practice. Scoring instruments had higher predictive ability for hospitalization after treatment than before treatment and may differ in their predictive ability after initial treatment. Definitive conclusions about the best instrument or meaningful comparison between instruments will require a study with a larger sample size.
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Affiliation(s)
- Michael D. Johnson
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Flory L. Nkoy
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
- Department of Biomedical Informatics, University of Utah School of
Medicine, Suite 140, 421 Wakara Way, Salt Lake City, UT 84108, USA
| | - Xiaoming Sheng
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Tom Greene
- Department of Population Health Sciences, University of Utah School
of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Bryan L. Stone
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Jennifer Garvin
- Department of Biomedical Informatics, University of Utah School of
Medicine, Suite 140, 421 Wakara Way, Salt Lake City, UT 84108, USA
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Baudin F, Buisson A, Vanel B, Massenavette B, Pouyau R, Javouhey E. Nasal high flow in management of children with status asthmaticus: a retrospective observational study. Ann Intensive Care 2017; 7:55. [PMID: 28534235 PMCID: PMC5440424 DOI: 10.1186/s13613-017-0278-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 05/10/2017] [Indexed: 11/30/2022] Open
Abstract
Background Asthma is the most common obstructive airway disease in children and adults. Nasal high flow (NHF) is a recent device that is now used as a primary support for respiratory distress. Several studies have reported use of NHF as a respiratory support in status asthmaticus; however, there are no data to recommend such practice. We therefore conducted this preliminary study to evaluate NHF therapy for children with status asthmaticus admitted to our PICU in order to prepare a multicentre randomized controlled study. Results Between November 2009 and January 2014, 73 patients with status asthmaticus were admitted to the PICU, of whom 39 (53%) were treated with NHF and among these 10 (26%) presented severe acidosis at admission (pH < 7.30). Thirty-four less severe children (41%) were treated with standard oxygen. For one child (2.6%) NHF failed and was then switched to non-invasive ventilation. NHF was discontinued in another patient because of the occurrence of pneumothorax after 31 h with NHF; the patient was then switched to standard oxygen therapy. Mean ± SD heart rate (165 ± 21 vs. 141 ± 25/min, p < 0.01) and respiratory rate (40 ± 13 vs. 31 ± 8/min, p < 0.01) decreased significantly, and blood gas improved in the first 24 h. In the subgroup of patients with acidosis, median [IQR] pH increased significantly between hour 0 and 2 (7.25 [7.21–7.26] vs. 7.30 [7.27–7.33], p = 0.009) and median [IQR] pCO2 decreased significantly (7.27 kPa [6.84–7.91 vs. 5.85 kPa [5.56–6.11], p = 0.007). No patient was intubated. Conclusion This retrospective study showed the feasibility and safety of NHF in children with severe asthma. Blood gas and clinical parameters were significantly improved during the first 24 h. NHF failed in only two patients, and none required invasive ventilation.
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Affiliation(s)
- Florent Baudin
- Réanimation pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Bron, France. .,UMR T_9405, UMRESTTE, Ifsttar, Université Claude Bernard Lyon1, Univ Lyon, 69373, Lyon, France.
| | - Alexandra Buisson
- Réanimation pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Bron, France
| | - Blandine Vanel
- Réanimation pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Bron, France
| | - Bruno Massenavette
- Réanimation pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Bron, France
| | - Robin Pouyau
- Réanimation pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Bron, France
| | - Etienne Javouhey
- Réanimation pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69500, Bron, France.,UMR T_9405, UMRESTTE, Ifsttar, Université Claude Bernard Lyon1, Univ Lyon, 69373, Lyon, France
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Paniagua N, Elosegi A, Duo I, Fernandez A, Mojica E, Martinez-Indart L, Mintegi S, Benito J. Initial Asthma Severity Assessment Tools as Predictors of Hospitalization. J Emerg Med 2017; 53:10-17. [PMID: 28416251 DOI: 10.1016/j.jemermed.2017.03.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/24/2017] [Accepted: 03/11/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Assessment tools to classify and prioritize patients, such as systems of triage, and indicators of severity, such as clinical respiratory scores, are helpful in guiding the flow of asthmatic patients in the emergency department. OBJECTIVE Our aim was to assess the performance of the Pediatric Assessment Triangle (PAT), triage level (TL), Pulmonary Score (PS), and initial O2 saturation (O2 sat), in predicting hospitalization in pediatric acute asthma exacerbations. STUDY DESIGN Retrospective study evaluating PAT, TL, and PS at presentation, and initial O2 sat of asthmatic children in the pediatric emergency department (PED). The primary outcome measure was the rate of hospitalization. Secondary outcomes were length of stay (LOS) in the PED and admission to the pediatric intensive care unit (PICU). RESULTS PAT, TL, PS, and initial O2 sat were recorded in 14,953 asthmatic children. Multivariate analysis yielded the following results: Abnormal PAT and more severe TLs (I-II) were independent risk factors for hospitalization (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.4-1.8; OR 3.4, 95% CI 2.6-4.3, respectively) and longer LOS (OR 1.5, 95% CI 1.3-1.7; OR 2.6, 95% CI 2-3.3, respectively). PS > 3 showed a strong association with hospitalization (OR 8.1, 95% CI 7-9.4), PICU admission (OR 9.6, 95% CI 3-30.9) and longer LOS (OR 6.2, 95% CI 5.6-6.9). O2 sat < 94% was an independent predictor of admission (OR 5.2, 95% CI 4.6-5.9), PICU admission (OR 4.6, 95% CI 4.5-4.6), and longer LOS (OR 4.6, 95% CI 4.1-5.2). CONCLUSIONS PAT, TL, PS, and initial O2 sat are good predictors of hospitalization in pediatric acute asthma exacerbations.
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Affiliation(s)
- Natalia Paniagua
- Pediatric Emergency Department, BioCruces Health Research Institute, Bilbao, Basque Country, Spain
| | - Amaia Elosegi
- Pediatric Emergency Department, BioCruces Health Research Institute, Bilbao, Basque Country, Spain
| | - Isabel Duo
- Pediatric Emergency Department, BioCruces Health Research Institute, Bilbao, Basque Country, Spain
| | - Ana Fernandez
- Pediatric Emergency Department, BioCruces Health Research Institute, Bilbao, Basque Country, Spain
| | - Elisa Mojica
- Pediatric Emergency Department, BioCruces Health Research Institute, Bilbao, Basque Country, Spain
| | - Lorea Martinez-Indart
- Epidemiology Unit, Cruces University Hospital, BioCruces Health Research Institute, Bilbao, Basque Country, Spain
| | - Santiago Mintegi
- Pediatric Emergency Department, BioCruces Health Research Institute, Bilbao, Basque Country, Spain
| | - Javier Benito
- Pediatric Emergency Department, BioCruces Health Research Institute, Bilbao, Basque Country, Spain
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Pound CM, Gelt V, Akiki S, Eady K, Moreau K, Momoli F, Murchison B, Zemek R, Mulholland B, Kovesi T. Nurse-Driven Clinical Pathway for Inpatient Asthma: A Randomized Controlled Trial. Hosp Pediatr 2017; 7:204-213. [PMID: 28330941 DOI: 10.1542/hpeds.2016-0150] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We examined the impact of a nurse-driven clinical pathway on length of stay (LOS) for children hospitalized with asthma. METHODS We conducted a randomized controlled trial involving children hospitalized with asthma. Nurses of children in the intervention group weaned salbutamol frequency using an asthma scoring tool, whereas physicians weaned salbutamol frequency for the control group patients as per standard care. The primary outcome was LOS in hours. Secondary outcomes included number of salbutamol treatments administered, ICU transfers, unplanned medical visits postdischarge, and stakeholders' pathway satisfaction. Research staff, investigators, and statisticians were blinded to group assignment, except for research assistants enrolling participants. Qualitative interviews were done to assess acceptability of intervention by physicians, nurses, residents, and patients. RESULTS We recruited 113 participants (mean age 4.9 years, 62% boys) between May 2012 and September 2015. Median LOS was 49 hours (21-243 hours) and 47 hours (22-188 hours) (P = .11), for the control and intervention groups, respectively. A post hoc analysis designed to deal with highly skewed LOS data resulted in a relative 18% (95% confidence interval 0.68-0.99) LOS reduction for the intervention group. There was no difference in secondary outcomes. No significant adverse events resulted from the intervention. The 14 participants included in the qualitative component reported a positive experience with the pathway. CONCLUSIONS This nurse-driven pathway led to increased efficiency as evidenced by a modest LOS reduction. It allowed for care standardization, improved utilization of nursing resources, and high stakeholder satisfaction.
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Affiliation(s)
- Catherine M Pound
- Children's Hospital of Eastern Ontario, Ontario, Canada; .,University of Ottawa, Ontario, Canada; and
| | - Victoria Gelt
- Children's Hospital of Eastern Ontario, Ontario, Canada.,University of Ottawa, Ontario, Canada; and
| | - Salwa Akiki
- Children's Hospital of Eastern Ontario, Ontario, Canada
| | - Kaylee Eady
- University of Ottawa, Ontario, Canada; and.,Children's Hospital of Eastern Ontario Research Institute, Ontario, Canada
| | - Katherine Moreau
- University of Ottawa, Ontario, Canada; and.,Children's Hospital of Eastern Ontario Research Institute, Ontario, Canada
| | - Franco Momoli
- University of Ottawa, Ontario, Canada; and.,Children's Hospital of Eastern Ontario Research Institute, Ontario, Canada
| | - Barbara Murchison
- Children's Hospital of Eastern Ontario Research Institute, Ontario, Canada
| | - Roger Zemek
- Children's Hospital of Eastern Ontario, Ontario, Canada.,University of Ottawa, Ontario, Canada; and.,Children's Hospital of Eastern Ontario Research Institute, Ontario, Canada
| | | | - Tom Kovesi
- Children's Hospital of Eastern Ontario, Ontario, Canada.,University of Ottawa, Ontario, Canada; and
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Wong J, Agus MSD, Graham DA, Melendez E. A Critical Asthma Standardized Clinical and Management Plan Reduces Duration of Critical Asthma Therapy. Hosp Pediatr 2017; 7:79-87. [PMID: 28096296 DOI: 10.1542/hpeds.2016-0087] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Reduction of critical asthma management time can reduce intensive care utilization. The goal of this study was to determine whether a Critical Asthma Standardized Clinical Assessment and Management Plan (SCAMP) can decrease length of critical asthma management time. METHODS This retrospective study compared critical asthma management times in children managed before and after implementation of a Critical Asthma SCAMP. The SCAMP used an asthma severity score management scheme to guide stepwise escalation and weaning of therapies. The SCAMP guided therapy until continuous albuterol nebulization (CAN) was weaned to intermittent albuterol every 2 hours (q2h). Because the SCAMP was part of a quality improvement initiative in which all patients received a standardized therapy, informed consent was waived. The study was conducted in Medicine ICU and Intermediate Care Units in a tertiary care freestanding children's hospital. Children ≥2 years of age who had CAN initiated in the emergency department and were admitted to the Division of Medicine Critical Care with status asthmaticus were included. The time to q2h dosing from initiation of CAN was compared between the baseline and SCAMP cohorts. Adverse events were compared. The Mann-Whitney test was used for analysis; P values <.05 were considered statistically significant. RESULTS There were 150 baseline and 123 SCAMP patients eligible for analysis. There was a decrease in median time to q2h dosing after the SCAMP (baseline, 21.6 hours [interquartile range, 3.2-32.3 hours]; SCAMP, 14.2 hours [interquartile range, 9.0-23.1 hours]; P < .01). There were no differences in adverse events or readmissions. CONCLUSIONS A Critical Asthma SCAMP was effective in decreasing time on continuous albuterol.
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Affiliation(s)
| | | | | | - Elliot Melendez
- Divisions of Medicine Critical Care and .,Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; and
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Lee E, Yoon J, Cho HJ, Hong SJ, Yu J. Respiratory reactance in children aged three to five years with postinfectious bronchiolitis obliterans is higher than in those with asthma. Acta Paediatr 2017; 106:81-86. [PMID: 27743492 DOI: 10.1111/apa.13632] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 08/29/2016] [Accepted: 10/12/2016] [Indexed: 11/27/2022]
Abstract
AIM We investigated airway function in preschoolers with postinfectious bronchiolitis obliterans (PIBO) using impulse oscillometry (IOS). METHODS This study enrolled 182 children aged three to five years: 12 with PIBO, 135 with asthma and 35 nonatopic controls. Respiratory resistance and reactance were assessed using IOS. RESULTS The percentage predicted (% predicted) of prebronchodilator respiratory resistance at 5 Hz was significantly higher in children with PIBO (177.9 ± 118.4%) than the asthma (126.1 ± 30.5%, p = 0.013) or control (121.1 ± 21.8%, p = 0.014) groups. After bronchodilator use, children with PIBO did not reach the values of Rrs5% predicted in the asthma and control groups. Respiratory reactance (Xrs5% predicted) in children with PIBO (337.1 ± 478.5%) was significantly higher than both asthma (130.0 ± 80.0%, p = 0.004) and control (105.1 ± 30.8%, p < 0.001) groups before bronchodilator use and significantly higher than the two groups after bronchodilator use (p = 0.010 and p = 0.004, respectively). The changes in Rrs5 and Xrs5 were not significantly different between the children with PIBO and asthma. CONCLUSION Measuring Rrs5 and Xrs5 before and after bronchodilator use may help to discriminate PIBO from asthma in children aged three to five years with chronic or recurrent respiratory symptoms.
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Affiliation(s)
- Eun Lee
- Department of Pediatrics; Inje University Haeundae Paik Hospital; Busan Korea
| | - Jisun Yoon
- Department of Pediatrics; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - Hyun-Ju Cho
- Department of Pediatrics; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - Soo-Jong Hong
- Department of Pediatrics; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - Jinho Yu
- Department of Pediatrics; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
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Dankoff S, Li P, Shapiro AJ, Varshney T, Dubrovsky AS. Point of care lung ultrasound of children with acute asthma exacerbations in the pediatric ED. Am J Emerg Med 2016; 35:615-622. [PMID: 28063721 DOI: 10.1016/j.ajem.2016.12.057] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVES Primary objective was to characterize lung ultrasound findings in children with asthma presenting with respiratory distress to the emergency department (ED). Secondary objectives included correlating these findings with patients' clinical course in the ED. METHODS Eligible patients 2-17years of age, underwent a lung ultrasound by the study sonographer between November 2014 to December 2015. Positive lung ultrasound was defined as the presence of ≥1 of the following findings: ≥3 B-lines per intercostal space, consolidation and/or pleural abnormalities. The treating physician remained blinded to ultrasound findings; clinical course was extracted from the medical chart. RESULTS A total of sixty patients were enrolled in this study. Lung ultrasound was positive in 45% (27/60) of patients: B-line pattern in 38%, consolidation in 30% and pleural line abnormalities in 12%. A positive lung ultrasound correlated with increased utilization of antibiotics (26% vs 0%, p=0.03), prolonged ED length of stay (30% vs. 9%, p=0.04) and admission rate (30% vs 0%, p=0.03). Inter-rater agreement between novice and expert sonographers was excellent with a kappa of 0.92 (95% CI: 0.84-1.00). CONCLUSIONS This study characterized lung ultrasound findings in pediatric patients presenting with acute asthma exacerbations; nearly half of whom had a positive lung ultrasound. Positive lung ultrasounds were associated with increased ED and hospital resource utilization. Future prospective studies are needed to determine the utility and reliability of this tool in clinical practice.
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Affiliation(s)
- Samantha Dankoff
- Division of Pediatric Emergency Medicine, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Patricia Li
- Department of Pediatrics, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Adam J Shapiro
- Department of Respirology, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Terry Varshney
- Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Alexander S Dubrovsky
- Pediatric Emergency Medicine, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada.
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Korang SK, Feinberg J, Wetterslev J, Jakobsen JC. Non-invasive positive pressure ventilation for acute asthma in children. Cochrane Database Syst Rev 2016; 9:CD012067. [PMID: 27687114 PMCID: PMC6457810 DOI: 10.1002/14651858.cd012067.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Asthma is one of the most common reasons for hospital admission among children and constitutes a significant economic burden. Use of non-invasive positive pressure ventilation (NPPV) in the care of children with acute asthma has increased even though evidence supporting the intervention has been considered weak and clinical guidelines do not recommend the intervention. NPPV might be an effective intervention for acute asthma, but no systematic review has been conducted to assess the effects of NPPV as an add-on therapy to usual care in children with acute asthma. OBJECTIVES To assess the benefits and harms of NPPV as an add-on therapy to usual care (e.g. bronchodilators and corticosteroids) in children with acute asthma. SEARCH METHODS We identified trials from the Cochrane Airways Group Specialised Register (CAGR). The Register contains trial reports identified through systematic searches of bibliographic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED and PsycINFO, and by handsearching of respiratory journals and meeting abstracts. We also conducted a search of ClinicalTrials.gov (www.ClinicalTrials.gov) and the WHO trials portal (www.who.int/ictrp/en/). We searched all databases from their inception to February 2016, with no restriction on language of publication. SELECTION CRITERIA We included randomised clinical trials (RCTs) assessing NPPV as add-on therapy to usual care versus usual care for children (age < 18 years) hospitalised for an acute asthma attack. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts. We retrieved all relevant full-text study reports, independently screened the full text, identified trials for inclusion and identified and recorded reasons for exclusion of ineligible trials. We resolved disagreements through discussion or, if required, consulted a third review author. We recorded the selection process in sufficient detail to complete a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flow diagram and 'Characteristics of excluded studies' table. We identified the risk of bias of included studies to reduce the risk of systematic error. We contacted relevant study authors when data were missing. MAIN RESULTS We included two RCTs that randomised 20 participants to NPPV and 20 participants to control. We assessed both studies as having high risk of bias; both trials assessed effects of bilateral positive airway pressure (BiPAP). Neither trial used continuous positive airway pressure (CPAP). Controls received standard care. Investigators reported no deaths and no serious adverse events (Grades of Recommendation, Assessment, Development and Evaluation (GRADE): very low quality of evidence due to serious risk of bias and serious imprecision of results). Both trials showed a statistically significant reduction in symptom score. One trial did not report a standard deviation (SD), but by using an estimated SD, we found a statistically significantly reduced asthma symptom score (mean difference (MD) -2.50, 95% confidence interval (CI) -4.70 to -0.30, P = 0.03, 19 participants, GRADE: very low quality of evidence). In the other trial, NPPV was associated with a lower total symptom score (5.6 vs 1.9, 16 participants, very low quality of evidence) before cross-over, but investigators did not report an SD, nor could it be estimated from the first phase of the trial, before the cross-over. These gains could be clinically relevant, as a reduction of three or more points in symptom score is considered a clinically meaningful change. Researchers documented five dropouts (12.5%), four of which were due to intolerance to NPPV, and one to respiratory failure requiring intubation. Owing to insufficient reporting in the latter trial and use of different scoring systems, it was not possible to conduct a meta-analysis nor a Trial Sequential Analysis. AUTHORS' CONCLUSIONS Current evidence does not permit confirmation or rejection of the effects of NPPV for acute asthma in children. Large RCTs with low risk of bias are warranted.
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Affiliation(s)
- Steven Kwasi Korang
- Holbaek SygehusPediatric DepartmentSmedelundsgade 60HolbaekDenmark4300
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchCopenhagenDenmark
| | - Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchCopenhagenDenmark
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchCopenhagenDenmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenSjællandDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
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Gattu R, Scollan J, DeSouza A, Devereaux D, Weaver H, Agthe AG. Telemedicine: A Reliable Tool to Assess the Severity of Respiratory Distress in Children. Hosp Pediatr 2016; 6:476-482. [PMID: 27450148 DOI: 10.1542/hpeds.2015-0272] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Remote assessment of respiratory distress using telemedicine enabled audio-video conferencing (TM) is of value for medical decision-making. Our goal was to evaluate the interobserver reliability (IOR) of TM compared with face-to-face (FTF) assessment of respiratory distress in children. METHODS A prospective, cohort study was performed in pediatric emergency department from July 2012 to February 2013. Children (aged 0-18 years) who presented with signs of respiratory distress were included in the study. The respiratory score is a 4-item, 12-point scale (respiratory rate [1-3], retractions [0-3], dyspnea [0-3], and wheezing [0-3]) that assesses the severity of a child's respiratory distress. Each child was evaluated by a pair of observers from a pool of 25 observers. The first observer evaluated the patient FTF, and the second observer simultaneously and independently evaluated remotely via TM. The overall respiratory distress severity is based on the respiratory scale and reported as nonsevere (≤8) and severe (≥9) respiratory distress. The IOR reliability between FTF and TM assessment was measured using a 2-way mixed model, absolute agreement and average measure intraclass correlation coefficient (ICC). RESULTS Forty-eight patients and 135 paired observations were recorded. IOR between the FTF and TM groups for total respiratory score had an ICC of 0.95 (confidence interval 0.93-0.96) and for subscores, the ICC range was as follows: respiratory rate = 0.92, retractions = 0.85, dyspnea = 0.94, and wheezing = 0.77. CONCLUSIONS TM is a reliable tool to assess the severity of respiratory distress in children.
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Affiliation(s)
| | | | - Amita DeSouza
- Department of Pediatrics, University of Maryland Medical Center; and
| | - Danielle Devereaux
- Department of Pediatrics, Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Alexander G Agthe
- Department of Pediatrics, Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland
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Clinical Scores for Dyspnoea Severity in Children: A Prospective Validation Study. PLoS One 2016; 11:e0157724. [PMID: 27382963 PMCID: PMC4934692 DOI: 10.1371/journal.pone.0157724] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/05/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In acute dyspnoeic children, assessment of dyspnoea severity and treatment response is frequently based on clinical dyspnoea scores. Our study aim was to validate five commonly used paediatric dyspnoea scores. METHODS Fifty children aged 0-8 years with acute dyspnoea were clinically assessed before and after bronchodilator treatment, a subset of 27 children were videotaped and assessed twice by nine observers. The observers scored clinical signs necessary to calculate the Asthma Score (AS), Asthma Severity Score (ASS), Clinical Asthma Evaluation Score 2 (CAES-2), Pediatric Respiratory Assessment Measure (PRAM) and respiratory rate, accessory muscle use, decreased breath sounds (RAD). RESULTS A total of 1120 observations were used to assess fourteen measurement properties within domains of validity, reliability and utility. All five dyspnoea scores showed overall poor results, scoring insufficiently on more than half of the quality criteria for measurement properties. The AS and PRAM were the most valid with good values on six and moderate values on three properties. Poor results were mainly due to insufficient measurement properties in the validity and reliability domains whereas utility properties were moderate to good in all scores. CONCLUSION This study shows that commonly used dyspnoea scores show insufficient validity and reliability to allow for clinical use without caution.
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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.
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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
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Schuh S, Sweeney J, Freedman SB, Coates AL, Johnson DW, Thompson G, Gravel J, Ducharme FM, Zemek R, Plint AC, Beer D, Klassen T, Curtis S, Black K, Nicksy D, Willan AR. Magnesium nebulization utilization in management of pediatric asthma (MagNUM PA) trial: study protocol for a randomized controlled trial. Trials 2016; 17:261. [PMID: 27220675 PMCID: PMC4879727 DOI: 10.1186/s13063-015-1151-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 12/30/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Up to 30 % of children with acute asthma are refractory to initial therapy, and 84 % of this subpopulation needs hospitalization. Finding safe, noninvasive, and effective strategies to treat this high-risk group would substantially decrease hospitalizations, healthcare costs, and the psycho-social burden of the disease. Whereas intravenous magnesium (Mg) is effective in severe refractory asthma, its use is sporadic due to safety concerns, with the main treatment goal being to prevent intensive care unit admission. In contrast, nebulized Mg is noninvasive, allows higher pulmonary drug concentrations, and has a much higher safety potential due to the lower rate of systemic delivery. Previous studies of inhaled Mg show disparate results due to the use of unknown/inefficient delivery methods and other methodological flaws. METHODS/DESIGN The study is a randomized double-blind controlled trial in seven Canadian pediatric Emergency Departments (two-center pilot 2011 to 2014, Canada-wide November 2014 to December 2017). The trial will include 816 otherwise healthy children who are 2 to 17 years old, having had at least one previous wheezing episode, have received systemic corticosteroids, and have a Pediatric Respiratory Assessment Measure (PRAM) ≥ 5 points after three salbutamol and ipratropium treatments for a current acute asthma exacerbation. Eligible consenting children will receive three experimental treatments of nebulized salbutamol with either 600 mg of Mg sulfate or placebo 20 min apart, using an Aeroneb Go nebulizer, which has been shown to maximize pulmonary delivery while maintaining safety. The primary outcome is hospitalization within 24 h of the start of the experimental therapy for persistent respiratory distress or supplemental oxygen. Secondary outcomes include all-cause hospitalization within 24 h, PRAM, vital signs, number of bronchodilator treatments by 240 min, and the association between the difference in the primary outcome between the groups, age, gender, baseline PRAM, atopy, and "viral induced wheeze" phenotype (Fig. 1). DISCUSSION If effective, inhaled Mg may represent an effective strategy to minimize morbidity in pediatric refractory acute asthma. Unlike previous works, this trial targets nonresponders to optimized initial therapy who are the most likely to benefit from inhaled Mg. Future dissemination of results will include knowledge translation, incorporation into a Cochrane Review, presentation at scientific meetings, and a peer-reviewed publication. TRIAL REGISTRATION NCTO1429415 , registered 2 September 2011.
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Affiliation(s)
- Suzanne Schuh
- />Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Child Health Evaluative Sciences, SickKids Research Institute, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - Judy Sweeney
- />SickKids Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8 Canada
| | - Stephen B. Freedman
- />Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
| | - Allan L. Coates
- />SickKids Research Institute, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - David W. Johnson
- />Departments of Paediatrics, Pharmacology and Physiology, Alberta Children’s Hospital Research Institute, Faculty of Medicine, University of Calgary, C4,643, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
| | - Graham Thompson
- />Division of Pediatric Emergency Medicine, Alberta Children’s Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
| | - Jocelyn Gravel
- />Division of Paediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, 3175 Cote Sainte-Catherine, Montreal, QC H3T 1C5 Canada
| | - Francine M. Ducharme
- />Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, 175 Cote Sainte-Catherine, Montreal, QC H3T 1C5 Canada
| | - Roger Zemek
- />Division of Pediatric Emergency Medicine, Children’s Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Amy C. Plint
- />Division of Emergency Medicine, Children’s Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Darcy Beer
- />Divsion of Pediatric Emergency Medicine, The Children’s Hospital of Winnipeg, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3J 1R9 Canada
| | - Terry Klassen
- />Children’s Hospital Research Institute of Manitoba (formerly Manitoba Institute of Child Health), Academic Faculty of Medicine, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Department of Pediatrics and Child Health, University of Manitoba, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Child Health Program, Winnipeg Health Region MICH, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
| | - Sarah Curtis
- />Division of Paediatric Emergency Medicine, Stollery Children’s Hospital, University of Alberta, 8440 112 Street Northwest, Edmonton, AB T6G 2B7 Canada
| | - Karen Black
- />Division of Pediatric Emergency Medicine, University of British Columbia, BC Children’s Hospital, 4480 Oak St, Vancouver, BC V6H 3N1 Canada
| | - Darcy Nicksy
- />SickKids Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8 Canada
| | - Andrew R. Willan
- />Child Health Evaluative Sciences, SickKids Research Institute, Dalla Lana School of Public Health, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - on behalf of Pediatric Emergency Research Canada Group
- />Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Child Health Evaluative Sciences, SickKids Research Institute, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
- />Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
- />Departments of Paediatrics, Pharmacology and Physiology, Alberta Children’s Hospital Research Institute, Faculty of Medicine, University of Calgary, C4,643, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
- />Division of Pediatric Emergency Medicine, Alberta Children’s Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6AB Canada
- />Division of Paediatric Emergency Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, 3175 Cote Sainte-Catherine, Montreal, QC H3T 1C5 Canada
- />Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, 175 Cote Sainte-Catherine, Montreal, QC H3T 1C5 Canada
- />Division of Pediatric Emergency Medicine, Children’s Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
- />Division of Emergency Medicine, Children’s Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
- />Divsion of Pediatric Emergency Medicine, The Children’s Hospital of Winnipeg, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3J 1R9 Canada
- />Children’s Hospital Research Institute of Manitoba (formerly Manitoba Institute of Child Health), Academic Faculty of Medicine, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Department of Pediatrics and Child Health, University of Manitoba, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Child Health Program, Winnipeg Health Region MICH, 715 McDermot Ave, Winnipeg, MB R3E 3P4 Canada
- />Division of Paediatric Emergency Medicine, Stollery Children’s Hospital, University of Alberta, 8440 112 Street Northwest, Edmonton, AB T6G 2B7 Canada
- />Division of Pediatric Emergency Medicine, University of British Columbia, BC Children’s Hospital, 4480 Oak St, Vancouver, BC V6H 3N1 Canada
- />SickKids Research Institute, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
- />Child Health Evaluative Sciences, SickKids Research Institute, Dalla Lana School of Public Health, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
- />SickKids Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8 Canada
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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.
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Korang SK, Feinberg J, Wetterslev J, Jakobsen JC. Non-invasive positive pressure ventilation for acute asthma in children. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Al-Moamary MS, Alhaider SA, Idrees MM, Al Ghobain MO, Zeitouni MO, Al-Harbi AS, Yousef AA, Al-Matar H, Alorainy HS, Al-Hajjaj MS. The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2016; 11:3-42. [PMID: 26933455 PMCID: PMC4748613 DOI: 10.4103/1817-1737.173196] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 12/21/2022] Open
Abstract
This is an updated guideline for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have guidelines that are up to date, simple to understand and easy to use by nonasthma specialists, including primary care and general practice physicians. SINA approach is mainly based on symptom control and assessment of risk as it is the ultimate goal of treatment. The new SINA guidelines include updates of acute and chronic asthma management, with more emphasis on the use of asthma control in the management of asthma in adults and children, inclusion of a new medication appendix, and keeping consistency on the management at different age groups. The section on asthma in children is rewritten and expanded where the approach is stratified based on the age. The guidelines are constructed based on the available evidence, local literature, and the current situation in Saudi Arabia. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.
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Affiliation(s)
- Mohamed S. Al-Moamary
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A. Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Majdy M. Idrees
- Department of Medicine, Pulmonary Division, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed O. Al Ghobain
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed O. Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Adel S. Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, University of Dammam, Dammam, Saudi Arabia
| | - Hussain Al-Matar
- Department of Medicine, Imam Abdulrahman Al Faisal Hospital, Dammam, Saudi Arabia
| | - Hassan S. Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed S. Al-Hajjaj
- Department of Medicine, Respiratory Division, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Al-Eyadhy AA, Temsah MH, Alhaboob AAN, Aldubayan AK, Almousa NA, Alsharidah AM, Alangari MI, Alshaya AM. Asthma changes at a pediatric intensive care unit after 10 years: Observational study. Ann Thorac Med 2015; 10:243-8. [PMID: 26664561 PMCID: PMC4652289 DOI: 10.4103/1817-1737.165302] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES: To describe the change in the management, and outcome of children with acute severe asthma (ASA) admitted to Pediatric Intensive Care Unit (PICU) at tertiary institute, as compared to previously published report in 2003. METHODS: This is a retrospective observational study. All consecutive pediatric ASA patients who were admitted to PICU during the study period were included. The data were extracted from PICU database and medical records. The Cohort in this study (2013 Cohort) was compared with the Cohort of ASA, which was published in 2003 from the same institution (2003 Cohort). RESULTS: In comparison to previous 2003 Cohort, current Cohort (2013) revealed higher mean age (5.5 vs. 3.6 years; P ≤ 0.001), higher rate of PICU admission (20.3% vs. 3.6%; P ≤ 0.007), less patients who received maintenance inhaled steroids (43.3% vs. 62.4%; P ≤ 0.03), less patients with pH <7.3 (17.9% vs. 42.9%; P ≤ 0.001). There were more patients in 2013 Cohort who received: Inhaled Ipratropium bromide (97% vs. 68%; P ≤ 0.001), intravenous magnesium sulfate (68.2% vs. none), intravenous salbutamol (13.6% vs. 3.6%; P ≤ 0.015), and noninvasive ventilation (NIV) (35.8% vs. none) while no patients were treated with theophylline (none vs. 62.5%). The median length of stay (LOS) was 2 days while mean LOS was half a day longer in the 2013 Cohort. None of our patients required intubation, and there was no mortality. CONCLUSION: We observed slight shift toward older age, considerably increased the rate of PICU admission, increased utilization of Ipratropium bromide, magnesium sulfate, and NIV as important modalities of treatment.
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Affiliation(s)
- Ayman A Al-Eyadhy
- Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Mohamad-Hani Temsah
- Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Ali A N Alhaboob
- Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Abdulmalik K Aldubayan
- Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Nasser A Almousa
- Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrahman M Alsharidah
- Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed I Alangari
- Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrahman M Alshaya
- Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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48
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Ducharme FM, Dell SD, Radhakrishnan D, Grad RM, Watson WT, Yang CL, Zelman M. Diagnosis and management of asthma in preschoolers: A Canadian Thoracic Society and Canadian Paediatric Society position paper. Paediatr Child Health 2015; 20:353-71. [PMID: 26526095 DOI: 10.1093/pch/20.7.353] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Asthma often starts before six years of age. However, there remains uncertainty as to when and how a preschool-age child with symptoms suggestive of asthma can be diagnosed with this condition. This delays treatment and contributes to both short- and long-term morbidity. Members of the Canadian Thoracic Society Asthma Clinical Assembly partnered with the Canadian Paediatric Society to develop a joint working group with the mandate to develop a position paper on the diagnosis and management of asthma in preschoolers. In the absence of lung function tests, the diagnosis of asthma should be considered in children one to five years of age with frequent (≥8 days/month) asthma-like symptoms or recurrent (≥2) exacerbations (episodes with asthma-like signs). The diagnosis requires the objective document of signs or convincing parent-reported symptoms of airflow obstruction (improvement in these signs or symptoms with asthma therapy), and no clinical suspicion of an alternative diagnosis. The characteristic feature of airflow obstruction is wheezing, commonly accompanied by difficulty breathing and cough. Reversibility with asthma medications is defined as direct observation of improvement with short-acting ß2-agonists (SABA) (with or without oral corticosteroids) by a trained health care practitioner during an acute exacerbation (preferred method). However, in children with no wheezing (or other signs of airflow obstruction) on presentation, reversibility may be determined by convincing parental report of a symptomatic response to a three-month therapeutic trial of a medium dose of inhaled corticosteroids with as-needed SABA (alternative method), or as-needed SABA alone (weaker alternative method). The authors provide key messages regarding in whom to consider the diagnosis, terms to be abandoned, when to refer to an asthma specialist and the initial management strategy. Finally, dissemination plans and priority areas for research are identified.
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Affiliation(s)
- Francine M Ducharme
- Departments of Pediatrics and of Social and Preventive Medicine, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Quebec
| | - Sharon D Dell
- Department of Pediatrics and IHPME, The Hospital for Sick Children, University of Toronto, Toronto
| | - Dhenuka Radhakrishnan
- Department of Pediatrics, Children's Hospital, London Health Sciences, Western University, London, Ontario
| | - Roland M Grad
- Department of Family Medicine, Jewish General Hospital, McGill University, Montreal, Quebec
| | - Wade Ta Watson
- Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia
| | - Connie L Yang
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia
| | - Mitchell Zelman
- Department of Pediatrics, Queen Elizabeth Hospital, Charlottetown, Prince Edward Island, Dalhousie University, Halifax, Nova Scotia
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49
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Ducharme FM, Dell SD, Radhakrishnan D, Grad RM, Watson WTA, Yang CL, Zelman M. Le diagnostic et la prise en charge de l’asthme chez les enfants d’âge préscolaire : document de principes de la Société canadienne de thoracologie et de la Société canadienne de pédiatrie. Paediatr Child Health 2015. [DOI: 10.1093/pch/20.7.362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Francine M Ducharme
- Départements de pédiatrie et de médecine sociale et préventive, Centre hospitalier universitaire Sainte-Justine, Université de Montréal, Montréal (Québec)
| | - Sharon D Dell
- Département de pédiatrie, The Hospital for Sick Children et Institute of Health Policy, Management and Evaluation, université de Toronto, Toronto (Ontario)
| | - Dhenuka Radhakrishnan
- Département de pédiatrie, Children’s Hospital, London Health Sciences Centre, université de Western Ontario, London (Ontario)
| | - Roland M Grad
- Département de médecine de famille, Hôpital général juif, Université McGill, Montréal (Québec)
| | - Wade TA Watson
- Département de pédiatrie, IWK Health Centre, université Dalhousie, Halifax (Nouvelle-Écosse)
| | - Connie L Yang
- Département de pédiatrie, British Columbia Children’s Hospital, université de la Colombie-Britannique, Vancouver (Colombie-Britannique)
| | - Mitchell Zelman
- Département de pédiatrie, Queen Elizabeth Hospital, Charlottetown (Île-du-Prince-Édouard), université Dalhousie, Halifax (Nouvelle-Écosse)
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50
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La prise en charge aux urgences de la crise d’asthme aiguë de l’enfant. ANNALES FRANCAISES DE MEDECINE D URGENCE 2015. [DOI: 10.1007/s13341-015-0560-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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