AAIRS Score Overview: The Acute Asthma Intensity Research Score

Prospective Observational Study of Clinical Outcomes After Intravenous Magnesium for Moderate and Severe Acute Asthma Exacerbations in Children

BACKGROUND

There is limited knowledge regarding whether intravenous magnesium (IV-Mg) improves outcomes in children with acute asthma exacerbations.

OBJECTIVE

To examine whether IV-Mg improves outcomes in children with moderate and severe exacerbations.

METHODS

We performed a secondary analysis using data from a prospective observational cohort of children aged 5 to 17 years with moderate and severe exacerbations. Standardized treatment included systemic corticosteroid and inhaled albuterol, with consideration of IV-Mg (75 mg/kg) for patients with insufficient response after 20 minutes. Propensity score (PS) models were used to examine associations of IV-Mg treatment with change in the validated Acute Asthma Intensity Research Score, hospitalization rate, and time to spacing of inhaled albuterol of 4 hours or more among hospitalized participants.

RESULTS

Among 301 children, median (interquartile range) age was 8.1 (6.4-10.2) years, 170 were Black (57%), 201 were male (67%), and 84 received IV-Mg (28%). In a PS covariate-adjusted multivariable linear regression model, IV-Mg treatment was associated with a 2-hour increase in the Acute Asthma Intensity Research Score (β-coefficient = 0.98; 95% confidence interval [CI], 0.20-1.77), indicating increased exacerbation severity. Three additional PS-based models yielded similar results. Participants receiving IV-Mg had 5.8-fold (95% CI, 2.8-11.9) and 6.8-fold (95% CI, 3.6-12.9) greater odds of hospitalization in PS-based multivariable regression models. Among hospitalized participants, there was no difference in time to albuterol of every 4 hours or more in a PS covariate-adjusted Cox proportional hazards model (hazard ratio = 1.2; 95% CI, 0.8-1.8).

CONCLUSIONS

Among children with moderate and severe exacerbations, IV-Mg is associated with increased exacerbation severity, increased risk for hospitalization, and no acceleration in exacerbation resolution among hospitalized participants.

Nebulized albuterol delivery is associated with decreased skeletal muscle strength in comparison with metered-dose inhaler delivery among children with acute asthma exacerbations

OBJECTIVE

Albuterol is a β2-agonist and causes an intracellular shift of potassium from the interstitium. Whole-body hypokalemia is known to cause skeletal muscle weakness, but whether this occurs as a result of hypokalemia from the intracellular shift during albuterol treatment is unknown. We sought to determine if albuterol total dose or route of administration (nebulization and/or metered-dose inhaler) is associated with skeletal muscle weakness.

METHODS

This was a prospective observational study using convenience sampling. Skeletal muscle strength was measured before and after 1 hour of albuterol treatment using a hand-grip dynamometer in participants aged 5-17 years with acute asthma exacerbation in the emergency department. We examined associations of albuterol dose and route of administration with changes in grip strength.

RESULTS

Among 50 participants, 10 received continuous albuterol by nebulizer and 40 received albuterol by metered-dose inhaler. The median (interquartile range) in change of grip was -7.8% (interquartile range, -23.3, +5.1) for those treated with a nebulizer and +2.4% (interquartile range, -5%, +12.7%) for those treated with a metered-dose inhaler (P = 0.036 for the difference). In a multiple linear regression model adjusted for the pretreatment Acute Asthma Intensity Research Score and age, participants treated with a nebulizer had a 12.9% decrease in skeletal muscle strength compared with those treated with a metered-dose inhaler.

CONCLUSION

Higher doses of albuterol administered via nebulization result in decreased skeletal muscle strength in patients with acute asthma; whereas, albuterol administration via metered-dose inhalers showed no effect on skeletal muscle strength.

Implementation and Improvement of Pediatric Asthma Guideline Improves Hospital-Based Care

BACKGROUND

Standardized pediatric asthma care has been shown to improve measures in specific hospital areas, but to our knowledge, the implementation of an asthma clinical practice guideline (CPG) has not been demonstrated to be associated with improved hospital-wide outcomes. We sought to implement and refine a pediatric asthma CPG to improve outcomes and throughput for the emergency department (ED), inpatient care, and the ICU.

METHODS

An urban, quaternary-care children's hospital developed and implemented an evidence-based, pediatric asthma CPG to standardize care from ED arrival through discharge for all primary diagnosis asthma encounters for patients ≥2 years old without a complex chronic condition. Primary outcomes included ED and inpatient length of stay (LOS), percent ED encounters requiring admission, percent admissions requiring ICU care, and total charges. Balancing measures included the number of asthma discharges between all-cause 30-day readmissions after asthma discharges and asthma relapse within 72 hours. Statistical process control charts were used to monitor and analyze outcomes.

RESULTS

Analyses included 3650 and 3467 encounters 2 years pre- and postimplementation, respectively. Postimplementation, reductions were seen in ED LOS for treat-and-release patients (3.9 hours vs 3.3 hours), hospital LOS (1.5 days vs 1.3 days), ED encounters requiring admission (23.5% vs 18.8%), admissions requiring ICU (23.0% vs 13.2%), and total charges ($4457 vs $3651). Guideline implementation was not associated with changes in balancing measures.

CONCLUSIONS

The hospital-wide standardization of a pediatric asthma CPG across hospital units can safely reduce overall hospital resource intensity by reducing LOS, admissions, ICU services, and charges.

Adapting an Evidence-Based Pediatric Acute Asthma Exacerbation Severity Assessment Tool for Pediatric Primary Care

INTRODUCTION

The purposes of this project were (a) to examine criteria derived from evidence-based pediatric acute asthma exacerbation assessment tools, asthma scores, and the acute asthma prediction rule validated and used in the emergency department and (b) to adapt these criteria for pediatric primary care.

METHOD

The three stages of the project included (a) identification of criteria in a literature review, (b) validation of the criteria by an expert panel, and (c) adaptation of the criteria in the design of an assessment tool.

RESULTS

The criteria were validated and adapted in the design of The Pediatric Acute Asthma Exacerbation Severity Assessment and Disposition Decision-Making Tool for Pediatric Primary Care.

DISCUSSION

The adaptation of criteria derived from the evidence and validated by an expert panel will inform and guide clinicians in assessing severity and support decision making in determining disposition of pediatric patients presenting with an acute asthma exacerbation in primary care.