Rising asthma admissions and self referral

Childhood respiratory symptoms and mental health problems: the role of intergenerational smoking

OBJECTIVE

The aim of this study was to investigate the potential role of youth smoking, parental cigarette smoking and parental anxiety/depressive disorders in the relationship between respiratory symptoms and mental health problems among youth.

WORKING HYPOTHESIS

Adjusting for both parental smoking and parental anxiety/depressive disorders in the association between respiratory symptoms and mental health problems among young persons will significantly reduce the strength of the observed relationship.

STUDY DESIGN

Prospective cohort study. PATIENT-SUBJECT SELECTION: Data were drawn from a school-based sample of 1709 young persons in Oregon.

METHODOLOGY

Physical and mental health data were collected on youth.

RESULTS

Respiratory symptoms were associated with significantly increased odds of mental health problems among youth. After adjusting for youth smoking, the relationship between respiratory symptoms and depressive disorders was no longer statistically significant. The relationships between respiratory symptoms and anxiety and depressive disorders were no longer significant after adjusting for parental smoking. Parental anxiety/depressive disorders did not appear to influence these relationships.

CONCLUSIONS

These results provide initial evidence that exposure to parental smoking may play a role in the observed co-occurrence of respiratory and mental health problems in youth, and youths' own smoking appears to influence the link with depressive disorders, but not anxiety disorders.

Correlation of clinical score to pulmonary function and oxygen saturation in children with asthma attack

BACKGROUND

The aim of this study is to demonstrate the importance of the relation between clinical score, pulse oximetry and spirometric tests in an asthma attack.

METHODS

In this randomized, double blind, observational study, 110 children (age 2-15 years) with an asthma attack who were admitted to emergency room were evaluated. Patient history, physical examination, clinical score and oxygen saturation were recorded in all patients; however pulmonary function tests were obtained only in 54 children who were over 5 years of age. The clinical score was derived from respiratory rate, wheezing, dyspnea and retractions.

RESULTS

Both oxygen saturation and spirometric tests were found to be significantly correlated with the clinical score in children.

CONCLUSION

The clinical score could be used for assessing the severity of the asthma attack particularly in developing countries where laboratory facilities are not available or pulmonary function tests are not feasible.

Is childhood asthma still underdiagnosed and undertreated in Istanbul?

BACKGROUND

Childhood asthma is reported to be underdiagnosed and undertreated worldwide. The purpose of the present study was to investigate the rate of underdiagnosis and undertreatment among children diagnosed with asthma in a tertiary reference center in Turkey.

METHODS

A questionnaire survey was carried out among the parents of 1134 patients diagnosed with asthma in a tertiary reference outpatient clinic.

RESULTS

Mean age of the patients was 4.9 years (range 1-17 years). Of these children 45.5% had recurrent asthma attacks (average 4.8 attacks per year) and 24.7% had only the symptom of vigorous fits of coughing. Although they had been symptomatic for 29.6 months, only 41.1% were diagnosed as having asthma before admission to the clinic. In this study group 61.3% had received some form of asthma treatment, but only 21.1% of all patients were treated according to the guidelines. The rate of treatment according to guidelines was lower in the children under 6 years of age than older children (18.8 vs 24.2%, respectively, P = 0.02).

CONCLUSIONS

Underdiagnosis and undertreatment of childhood asthma still seem to be a major problem in the management of childhood asthma, especially in preschool children, even after the recommendations of guidelines.

Inadequate asthma treatment practices and noncompliance in Israel

Childhood asthma morbidity and mortality are increasing despite improvements in asthma therapy. The changes over the past decade in the guidelines for treatment of children with severe asthma have led to a reduction in admissions and readmissions to the pediatric intensive care unit (PICU). The Israeli medical infrastructure is exemplary in its capability of extending appropriate medical services to its entire population. Our objective was to look at the background of preventive maintenance treatment and treatment during an acute episode in children admitted to PICUs with severe asthma, and to identify areas that could be targeted for change. A 5-year retrospective chart audit on acute asthma admissions was conducted in two PICUs of general community hospitals representative of the provision of medical care in Israel. The prehospitalization preventive management and acute treatment prior to PICU admission were evaluated, and the number of admissions and readmissions was recorded. The index admission was the first episode of acute asthma for only 3% of the children: 25% of patients required readmission, and 15% of these to the PICU. In spite of a proven history of acute exacerbations of the disease, only 60% were on continuous treatment between attacks, and 29% of them had abruptly discontinued treatment, most of them shortly before the onset of the index attack. Inhaled steroids were used as maintenance and preventive treatment by less than one-third of the children, with the other two-thirds receiving mainly beta-2 agonists drugs. In conclusion, an unacceptably large proportion of asthmatic children do not receive the recommended maintenance and preventive treatment because of poor compliance, lack of education, or insufficient healthcare provision. This has probably led to avoidable recurrences of acute asthma exacerbations and unnecessary use of PICU facilities. These findings suggest that steps for implementing recommended guidelines and an educational program are needed.

[Epidemiology of respiratory allergy in children]

Epidemiology of paediatric respiratory allergic disorders allows the approach to causal and preventive risk factors by studying groups or sub groups of children in different locations and under different conditions. This is, however, complicated by the lack of consensus on disease definitions, which renders comparisons between studies difficult. Atopy is usually defined by the presence of positive skin tests (wheal size of at least a mean diameter > or = 3 mm), by the presence of specific IgE, or by the presence of increased total IgE (> or = 100 UI/mL). Infantile asthma is not well defined, complicated by the high prevalence of bronchiolitis; one thus questions between wheezing or wheezy bronchitis. Prevalence is high: among early wheezers, two populations will be defined by the medium term evolution: transient wheezers and persistent wheezers. Risk factors for these two conditions are different. Childhood asthma may be defined by the diagnosis of asthma (specific but fairly non-sensitive), by asthmatic symptoms (wheezing, waking by an attack of shortness of breath) (sensitive but not very specific), or by the combination of symptoms and airway hyperresponsiveness. The ISAAC study has standardised a questionnaire to assess the prevalence of asthma. The preliminary results show that there are wide variations across the world. The prevalence is low in Africa and Asia, intermediate in Europe, and high in Anglo-Saxon countries. The prevalence of asthma has gradually increased over the past 20 years in developed countries. Asthma and atopy are closely associated in children. Risk factors are genetic, associated with sex and environmental factors. Among these, allergic sensitisation is associated with the degree of exposure to allergens. Westernization of way of life is associated with increased prevalence of atopy, allergic rhinitis and asthma. Atopy seems inversely correlated to certain infections. Passive smoking is clearly associated with early wheezing. This and atmospheric pollution aggravate childhood asthma. However, the inducing role of pollution on asthma is still controversial.

Structured discharge procedure for children admitted to hospital with acute asthma: a randomised controlled trial of nursing practice

BACKGROUND

Discharge planning is becoming an important part of the management of childhood asthma in hospital. Readmission to hospital, although often inevitable, might represent a failure of the opportunity for intervention presented by a brief period of supervised care in hospital.

AIM

To examine the impact of a structured, nurse-led discharge package for children admitted to hospital with acute asthma on readmission to hospital, reattendance at the accident and emergency (A&E) department, and general practitioner consultations for asthma.

METHODS

A structured nurse-led discharge package, consisting of a 20 minute patient education programme and self management plan for children with asthma was developed on the wards of a busy children's hospital. A randomised controlled trial was conducted involving 160 children aged 2-16 years admitted for asthma over a 12 month period. Readmission and A&E reattendance's over the six months after discharge from hospital were obtained from the hospital computerised information system and general practitioner consultations from practice records.

RESULTS

Children in the intervention group were significantly less likely to be readmitted to hospital in the next six months than those in the control group (12 of 80 v 30 of 80 patients), and significantly less likely to attend the A&E department (6 of 80 v 31 of 80). Significantly fewer children in the intervention group had visits to their general practitioner for problematic asthma (31 of 78 v 72 of 77 for whom data were available).

CONCLUSION

By delivering the simplest form of education and support during a child's stay in hospital, readmissions over a six month period were reduced. The programme was designed to be suitable for administration by nursing staff on the children's wards after a brief period of training.

Characteristics of children having multiple Medicaid-paid asthma hospitalizations

OBJECTIVES

We undertook this population-based study to describe the characteristics of poor children with multiple asthma hospitalizations and to discern if poor minority children have a greater risk for these events than poor white children.

METHODS

We conducted a retrospective analysis of 1994 California hospital discharge data for asthma hospitalizations among 1 to 12-year-old Medicaid patients (N = 6844 discharges). Risk factors for multiple Medicaid asthma hospitalizations were calculated by using logistic regression procedures.

RESULTS

In 1994, asthma hospitalizations accounted for 11.6% of Medicaid-funded hospitalizations for 1 to 12-year-olds in California. These hospitalizations had a mean length of 2.7 days and a mean hospital charge of $6532. After we controlled for source of admission and length of stay, African American children (OR, 1.93; 95% CI 1.49-2.49) and Latino children (OR, 1.34; 95% CI 1.04-1.72) had a higher risk of multiple Medicaid-paid hospitalizations for asthma than did white children. Adjusted odds ratios for multiple asthma hospitalizations were 1.35 (CI, 1.05-1.74) for children with emergency room admissions, and 1.16 (CI, 0.97-1.39) for children having hospital stays of at least 5 days duration.

CONCLUSIONS

Among children with Medicaid-paid hospitalizations for asthma, the risk for multiple asthma hospitalizations within a year was greater among African Americans and Latinos than among whites. Programs attempting to decrease repeat hospitalizations for asthma may benefit by focusing on these populations.

[Evaluation of a program for asthmatic children treated in primary care outpatient units in Embu, São Paulo, 1988-1993]

The main objective of this study was to evaluate the effectiveness of the Program Targeting Children with 'Chest Wheezing' carried in the city of Embu, São Paulo. The study analyzed a total of 434 children aged zero to 14 years, admitted to the program from May 1988 to July 1993. Over 90% had never been treated for this medical problem in outpatient clinics. Only 6.2% had to be referred to other health care services during follow-up in this program. The program successfully performed clinical diagnosis of asthma in children over 2 years of age. The moderate and severe cases followed up for over a year showed the best clinical evolution, with the positive factor being better compliance with medication. The number of exacerbations decreased among the severe patients after a year of regular follow-up, although patients used bronchodilators during the 12 months of our analysis. Of the children enrolled, 53.2% gave up treatment principally in the first six months, most of them from the moderate group. We concluded that children with steadier compliance with the program benefited in spite of both the simplicity and the lack of some currently existing medications.

Decreasing admissions for childhood asthma to a Swedish county hospital

Hospital admission rates for childhood asthma have increased in many countries. To study if this is also true for Norrköping Hospital, paediatric admission rates for asthma every fifth year were examined for the period 1973 to 1993. Admission rates were found to have fallen over the last 10 years, especially in children of school age. Among the younger age groups (below 5 years of age) a fall in admission rates was also observed over the last 5 years. This fall occurred in spite of reported increases in the prevalence of childhood asthma. The relative risk for admission due to asthma thus decreased from 1 in 1973 to 0.09 in 1993. The readmission rate has been stable. The mean length of stay in hospital for asthma decreased significantly. The observed decreasing trend in hospital admissions for childhood asthma is contrary to that found in many other countries. Possible explanations are discussed.

Clinical management of asthma in the 1990s. Current therapy and new directions

Asthma is a serious global health problem affecting nearly 100 million people worldwide. Its rising prevalence and associated morbidity and mortality are of increasing concern. Traditionally, symptomatic control of bronchoconstriction with beta 2 agonists and theophylline has been the mainstay of therapy. However, during recent years, inflammation has been recognised as the predominant cause of reversible airway obstruction and airway hyperreactivity. As a result, the emphasis in treatment has shifted to the early use of inhaled corticosteroids to control airway inflammation. beta 2 agonists are best used on an as-needed basis for the relief of acute bronchoconstriction and for the prevention of exercise-induced asthma. Sustained release theophylline or an inhaled long-acting beta 2 agonist may effectively control nocturnal symptoms. Preliminary studies involving agents active in the 5-lipoxygenase pathway as preventive therapy are encouraging. Further studies are needed to define their role in the management of asthma.

Pilgrim's progress: the effect of salmeterol in older children with chronic severe asthma

Twenty-four children aged 12-17 years entered a randomized, double-blind placebo-controlled study investigating the use of salmeterol in chronic severe asthma. In addition to their usual medication, the children were given either placebo or 100 micrograms salmeterol b.d. by dry powder inhalation. Treatment was continued throughout one term at a residential school for asthma. Symptom scores, peak expiratory flow rates, spirometry and quality-of-life scores were compared between the two treatment groups. One child withdrew during the run-in period. Twelve pupils received placebo and 11 pupils received salmeterol. There were consistent improvements in favour of salmeterol, reaching statistical significance for morning and evening peak flow rates and spirometry when measured on four occasions during the study period. There were no medication-related adverse events recorded and no pulse rate changes. Salmeterol (100 micrograms b.d.) is well tolerated and efficacious in older children with chronic severe asthma.

Effect of continuous treatment with topical corticosteroid on episodic viral wheeze in preschool children

Acute episodic wheeze related to viral infections is a common and distressing condition and treatment remains unsatisfactory. Although some benefit from the continuous use of inhaled steroids has been demonstrated in young wheezy children, their effect primarily on acute episodes has not been considered. In this study the effect of budesonide (400 micrograms/day) was assessed in a four month double blind parallel trial, in 41 children (0.7-6.0 years) with predominantly episodic viral wheeze. Analysis of the last three months showed no difference between budesonide or placebo in mean daily total symptom score (median values 0.6 and 0.63), episode number (mean values 2.6 and 2.4), or score/episode (mean value 30 and 31). Four months of treatment with inhaled budesonide had no effect on acute episodes of wheeze in this group of children.

Appropriateness of paediatric admission

A study of the 'appropriateness' of 267 consecutive emergency admissions to a district paediatric department showed that admission was at a peak in the evening and night time. Breathing difficulty, head injury, and fever were the commonest presenting problems. Sixty three per cent of admissions occurred between 6 pm and 8 am and these were more likely to be after self referral to the accident and emergency department and were evenly distributed through the social classes. Overall 80.5% of admissions were considered to be necessary on medical grounds by the consultants at the time of discharge. Parental assessment of severity of illness and need for admission correlated well with that of the doctors. Fifty two per cent of all admissions took place though the accident and emergency department, and although a higher number of these were from disadvantaged families these were equally appropriate on medical grounds to those sent for admission by the general practitioner. Altogether 26.5% of admissions were for less than 24 hours and half of these were judged to be unnecessary. Implications for the organisation of inpatient care are discussed.

Rates of admission to hospital for asthma

OBJECTIVE

To describe trends in hospital admission rates for asthma in England and Wales (1976-85), the East Anglian region (from 1976 to 1991-2), and Wales (1980-90).

DESIGN

Descriptive study.

SETTING

Hospitals in England and Wales; hospitals in the East Anglian Regional Health Authority; hospitals in Wales.

MAIN OUTCOME MEASURES

Hospital admissions for asthma as principal diagnosis in England and Wales (Hospital In-patient Enquiry, 1976-85), for the East Anglian region (Hospital In-patient Enquiry, 1976-7; Hospital Activity Analysis, 1978-86; Regional Information System, 1987-8 to 1991-2), and for Wales (Hospital Activity Analysis, 1980-90).

RESULTS

Rates for England and Wales as a whole showed a steady upward trend throughout the period examined. Rates in East Anglia, though they were similar to the national trends in the early years, showed a peak in 1985 (for males and females) with some indication of a decline in rates thereafter. Rates for Wales showed an upward trend until 1988 (for both males and females) after which they showed a decline.

CONCLUSIONS

Interpretation of the East Anglian trends is made more difficult by the change in England in 1987 of the system for the collection of hospital admission data. The fact that the rates for the East Anglian region seem to decline before this change and other considerations suggest that the observed trends, although partly reflecting the disruption of the coding during the changeover in systems, may not be entirely artefactual. The possible roles of diagnostic transfer and changes in the delivery of care, asthma treatment, admission and readmission policies, and the severity and prevalence of asthma in changing admission rates are considered. The changing trends in admission rates for East Anglia and Wales reflect recently published trends for mortality from asthma in England.

Asthma at the interface: bridging the gap between general practice and a district general hospital

A clinic supervised by a nurse, using principles originally developed in general practice, was established in the paediatric department of a district general hospital. A randomised controlled study was conducted comparing children admitted with asthma or attending outpatients who were given a patient education programme and self management plan (intervention group) with a control group. The study comprised 91 patients aged 3-14 years admitted for asthma or attending a hospital outpatient department from November 1989 to November 1990. Seventy seven patients completed the study and kept diaries for a median of 283 days. Patients in the intervention group had significantly less restriction of activity (95% confidence interval (CI) -0.27 to -0.01) and fewer episodes of peak flow below 30% of best (95% CI 0.03 to 1.17). Patients in the intervention group were more likely to make the correct response to an acute exacerbation of their asthma than the control group (71% v 47%, 95% CI 9.51 to 39.1). The intervention group had fewer school absences and fewer home visits by a general practitioner. There was an increase in the readmission rate for the intervention group. A subgroup of patients who self managed by doubling their use of inhaled steroids during an exacerbation performed better than those patients who only increased their bronchodilator or were managed on salbutamol or sodium cromoglycate alone. Improvements in patient follow up and the structure of the self management plans used, particularly changing the peak flow level at which inhaled steroids are doubled, may further improve the outcome of patients attending the asthma clinic.

Risk factors for readmission to hospital for asthma in childhood

BACKGROUND

Readmissions account for part of the increase in hospital admissions for asthma in childhood seen in many countries.

METHODS

This observational study recorded demographic features and the severity, treatment and management of asthma in 1034 individual children admitted to hospital over a one year period, followed for a maximum of 33 months.

RESULTS

Readmissions were common, with 33% readmitted by six months and 51% by two years. After controlling for a wide range of variables, factors that significantly increased readmission were: female sex (relative risk (RR) 1.23; 95% confidence interval (CI) 1.03 to 1.46), young age (age < 5 years RR 1.71; 95% CI 1.41 to 2.08), number of previous admissions (one previous admission RR 1.32; two, RR 1.68; three, RR 2.00; four or more, RR 2.80), and inpatient intravenous treatment (RR 1.29; 95% CI 1.08 to 1.55). Inpatient treatment with theophylline was used frequently (98.4%), but was associated with decreased readmissions (RR 0.51, 95% CI 0.28 to 0.92). Factors which did not predict readmission included ethnicity, respiratory and pulse rate, medical team, prescribed prophylactic treatment, type of follow up, or the use of action plans.

CONCLUSIONS

Risk factors for readmission relate to the characteristics of the individual (age and sex), severity of the condition (intravenous treatment), and number of previous admissions which may reflect severity or behaviour of the illness. Medical treatment and management did not influence readmissions. Strategies to reduce the high readmission rate for asthma in childhood need to be developed.

Audit strategies to reduce hospital admissions for acute asthma

An eightfold rise in hospital admissions for acute asthma from 1971-85 prompted two studies to audit the admissions policy at the Royal Alexandra Hospital. In the first study the on call senior house officer (SHO) was replaced by an experienced registrar and over a four month period 53 children out of 158 were sent home from the receiving room compared with six out of 39 seen by the SHOs. In the second study an SHO training programme was established together with a home treatment package. Over a 12 month period the on call SHOs assessed 687 children with acute asthma; 229 (43.5%) were deemed fit to be sent home. Only seven of these were readmitted within one week. Diary symptom score cards filled in by parents indicated that children sent home without admission fared no worse at home than those admitted and then discharged for the two weeks after leaving hospital. The development of strategies to improve assessment and immediate management in the hospital receiving room can reduce hospital admissions for acute asthma, allowing more children to be safely managed in the community.

Prevention of viral induced asthma attacks using inhaled budesonide

Thirty two preschool children were entered into a double blind, placebo controlled study using intermittent budesonide to treat viral induced wheeze. Active treatment was either 800 micrograms twice a day via a spacer or 1600 micrograms twice a day via a spacer and facemask in those children too young to use a mouthpiece. Treatment was started at the onset of an upper respiratory tract infection and continued for seven days or until symptoms had resolved for 24 hours. Each child remained in the study until they had completed using one pair of budesonide and placebo inhalers in random order without the need for additional oral prednisolone. Twenty five children completed 28 treatment pairs. All 25 families were asked to express a preference after completing their first treatment pair: 12 preferred budesonide and six preferred placebo; seven had no preference. Symptom scores were compared in 17 treatment pairs that were completed without the need for oral prednisolone. Mean day and night time wheeze in the first week after infection were significantly lower in those receiving budesonide. Intermittent inhalation of budesonide can modify the severity of wheezing in preschool children developing asthma after viral respiratory infections but improvements were modest with the doses used in this study.

Crisis in asthma care

Reports of increases in both hospitalizations and deaths due to asthma have provided a sense of crisis in asthma care. This article examines issues concerning this sense of crisis. The authors review current trends in prevalence, morbidity, hospitalization, and mortality from asthma and examine possible reasons for changes that have occurred. A review of data suggesting that asthma can result in irreversible, chronic airway obstruction is presented. Finally, the authors discuss the role of the primary care physician in the management of asthma.

Management of asthma in pre-school children

The management of asthma in pre-school children often presents physicians with challenging problems. This article addresses the diagnostic criteria by which the diagnosis may be made, discusses the prognosis of untreated asthma and states the principles underlying the treatment of asthma in this age group. The management according to a stepwise protocol is discussed with reference both to maintenance therapy, and the treatment of acute severe asthma. The methods by which appropriate medication may be delivered are also described.

Evaluation of the properties and reliability of a clinical severity scale for acute asthma in children

The inter-observer agreement (reliability) and validity of a clinical asthma severity scale (ASS) derived from separate scores of wheeze, heart rate and accessory muscle use (each on a 4-point scale) were studied in 60 children aged between 6 months and 17 years (mean 5.4 years). Independent assessments of these clinical parameters were made by two paediatricians, and they also rated patients as having a mild, moderate, severe or very severe acute episode (clinical judgement rating, CJR). Oxygen saturation (SaO2) was measured concurrently by a Biox 3700 pulse oximeter and readings were categorized as mild (SaO2 greater than or equal to 94%), moderate (91-93%) and severe (less than 91%). Agreement between clinicians was assessed by the weighted kappa statistic (kappa W). Agreement for the ASS score compared to the severity grade obtained from SaO2 was slight (kappa W = 0.34) and compared to CJR the kappa W was 0.55. An ASS score of moderate or worse (greater than 3) had sensitivity of 97% and specificity of 50% for prediction of admission. The maximum frequency and duration of nebulizer therapy following admission were significantly greater for severe patients than for moderate patients. Length of hospital stay did not reflect the ASS score in the emergency department but total duration of functional disability increased with ASS score. The substitution of an adjusted heart rate score for the raw heart rate score used in ASS detracted from scale performance. The ASS is an imprecise but reasonable quantitative measure of the severity of an acute episode of asthma.(ABSTRACT TRUNCATED AT 250 WORDS)

Home nebulisers in childhood asthma: survey of hospital supervised use

OBJECTIVE

To review the management of and outcome in asthmatic children using home nebulisers under hospital supervision.

DESIGN

Postal questionnaires sent to parents.

SETTING

Paediatric departments of a children's hospital and a district general hospital.

SUBJECTS

Parents of 93 asthmatic children who had been loaned home nebulisers for administration of bronchodilators with verbal instructions on their use.

MAIN OUTCOME MEASURES

Drugs administered with nebuliser, side effects, frequency of hospital admission, and theoretical management of a severe attack.

RESULTS

84 children took salbutamol and 37 received more than 10 mg a day during attacks; side effects were reported in 54 children. Parents of 16 children said that they would give another dose of bronchodilator rather than seek medical help if their child failed to respond to the first dose. Since being loaned nebulisers 65 children were admitted to hospital less frequently and 16 were not readmitted; over two thirds of parents thought that there had been a marked improvement in their child's asthma.

CONCLUSIONS

Home nebulisers are valuable in childhood asthma. Excessive doses of bronchodilators may be given, however, and a weight related dose may be more appropriate. Parents should be given written as well as verbal instructions, especially regarding the management of severe attacks.

Efficacy, results, and complications of mechanical ventilation in children with status asthmaticus

We have conducted a retrospective survey of 79 children out of a total hospital asthmatic patient population of 2,412, admitted over a 32 month period to the ICU for the management of severe status asthmaticus. All patients were in severe respiratory distress with CO2 retention; 19 required mechanical ventilation due to increasing fatigue and worsening bronchospasm, having failed to respond to either inhaled or IV bronchodilator therapy. All patients were ventilated at slow rates (less than 12 min) and their airway pressure (Paw) was deliberately kept below 45 cmH2O, while accepting a PaCO2 in the 45-60 mmHg range, as long as the pH was compensated. Although two patients developed pneumothoraces while on positive pressure ventilation, these were resolved without incidents. Five patients who had mediastinal or subcutaneous air leaks prior to intubation did not develop pneumothoraces. Following the initiation of mechanical ventilation, IV beta-agonist therapy was increased in order to reverse the bronchospasm and reduce the duration of mechanical ventilation. Mean duration of intubation was 42 hours. Fourteen of the 19 patients were weaned and extubated within 48 hours. All patients survived without sequelae. We conclude that a degree of controlled "hypoventilation" by deliberately choosing Paw less than 45 cmH2O can be successfully used to ventilate children with severe status asthmaticus with a reduced rate of pressure-related complications.

Mechanical ventilation of paediatric patients with asthma: short and long term outcome

In the 7 years from 1982 to 1988, 10,639 children with acute asthma were admitted to the Royal Children's Hospital, Melbourne. Of these, 262 children (2%) were treated in the Intensive Care Unit. Twenty-seven required mechanical ventilation on 34 occasions, being 0.3% of hospital asthma admissions. Five patients died, four due to brain death following respiratory arrest prior to intubation. The main complications were (i) barotrauma, which occurred in five patients on seven occasions (20%); (ii) a reversible myopathy which occurred in three patients treated with high dose corticosteroids and muscle relaxants. Follow-up of patients ventilated in intensive care revealed that all but one of the initial survivors was alive 1-5 years later, all patients required subsequent readmission to hospital for treatment of acute asthma and 78% had persistent rather than episodic asthma. Although uncommon, an episode of ventilation has a major impact on the family's understanding and future management of acute asthma.

Trends and district variations in the hospital care of childhood asthma: results of a regional study 1970-85

Trends and district variations in the pre-hospital and hospital care of children aged 0-14 years admitted with acute asthma were surveyed in all 13 districts of a health region by examining case notes for 1970, 1978, and 1985. From 1970 to 1985 there was a substantial increase in admissions and some reduction of hospital stay. Over this time adrenergic drugs remained the most frequently used treatment with a large shift towards selective beta2 agonists administered by nebulisation. Use of corticosteroids fell in the under 5s with a decrease in the parenteral route of administration but rose in the 5-14 age group with an increase in the oral route of administration. There was an increase the use of oral xanthines but this was outweighed by falls in the use of suppositories and in parenteral administration. The use of antibiotics became less frequent and that of sedatives and antihistamines fell to almost nil. There were also important changes in other aspects of management, notably an increase in the use of lung function tests (from 3% to 70%) and falls in the use of chest radiographs, blood tests, bacteriology, and physiotherapy. In nearly all aspects of management there were significant and often very extreme variations in practice between districts, which were unlikely to be explained by differences in morbidity. These variations would be a suitable focus for medical audit, with the aim of establishing which treatment regimens have the best outcome and avoiding unnecessary cost and discomfort. Because early hospital drug treatment is closely related to the type of treatment given before admission such audit activities would need to include general practitioners.

Treatment of acute, episodic asthma in preschool children using intermittent high dose inhaled steroids at home

In a double blind, controlled trial, the effect of high dose beclomethasone dipropionate (750 micrograms three times daily for five days) administered by metered dose inhaler and valved spacer, was compared with placebo, during 70 paired episodes of acute asthma in 24 preschool children. Treatment commenced at home at the first sign of an attack. Parents' blind preference for active treatment was significant. Data from 17 pairs of treatment, however, were affected by interventions such as hospital admission or oral corticosteroid treatment. These events occurred similarly in active and control periods. An intrasubject comparison was made of diary scores from the 18 pairs of episodes in which no intervention occurred in either the active or placebo treatment. Both daytime and night symptoms over the first week of the attack were significantly reduced by active treatment. Intermittent high dose inhaled beclomethasone dipropionate is beneficial in modifying the severity of acute episodic asthma in preschool children able to use a spacer device.

Food and drug reactions, wheezing, and eczema in preterm infants

Allergic reactions were investigated in 777 preterm infants who were randomly assigned to early diet and followed up to 18 months post term. Wheezing or asthma was common (incidence 23%); it was associated with neonatal ventilation, maternal smoking, and a family history of atopy and was unexpectedly reduced in babies born by caesarean section. Even in non-ventilated infants, the incidence of subsequent wheezing was 18%, rising to an estimated 44% (using logistic regression) when the foregoing risk factors (excluding ventilation) were present. Eczema occurred in 151 infants (19%) and was strongly associated with multiple pregnancy (30% incidence in twins or triplets). Reactions to cows' milk (incidence: 4.4% from detailed history; 0.8% confirmed by challenge), other foods (10%), and drugs (5%) were within the range reported in full term infants. Milk and food reactions were associated with multiple pregnancy (19%) and a family history of atopy. Reactions to drugs were least likely to occur in infants who had been ventilated and were on multiple medications in the neonatal period, suggesting that drug tolerance may have developed. We speculate that preterm infants may be a high risk group for asthma and eczema, which could imply an association between atopy and prematurity.