Long term outcome of ventilated asthmatics

Family Outcomes After the Pediatric Intensive Care Unit: A Scoping Review

BACKGROUND

Intensivists are increasingly attuned to the postdischarge outcomes experienced by families because patient recovery and family outcomes are interdependent after childhood critical illness. In this scoping review of international contemporary literature, we describe the evidence of family effects and functioning postpediatric intensive care unit (PICU) as well as outcome measures used to identify strengths and weaknesses in the literature.

METHODS

We reviewed all articles published between 1970 and 2017 in PubMed, Embase, PsycINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL), or the Cochrane Controlled Trials Registry. Our search used a combination of terms for the concept of "critical care/illness" combined with additional terms for the prespecified domains of social, cognitive, emotional, physical, health-related quality of life (HRQL), and family functioning.

RESULTS

We identified 71 articles reporting on the postPICU experience of more than 2400 parents and 3600 families of PICU survivors in 8 countries. These articles used 101 different metrics to assess the various aspects of family outcomes; 34 articles also included open-ended interviews. Overall, most families experienced significant disruption in at least five out of six of our family outcomes subdomains, with themes of decline in mental health, physical health, family cohesion, and family finances identified. Almost all articles represented relatively small, single-center, or disease-specific observational studies. There was a disproportionate representation of families of higher socioeconomic status (SES) and Caucasian race, and there was much more data about mothers compared to fathers. There was also very limited information regarding outcomes for siblings and extended family members after a child's PICU stay.

CONCLUSIONS

Significant opportunities remain for research exploring family functioning after PICU discharge. We recommend that future work include more diverse populations with respect to the critically ill child as well as family characteristics, include more intervention studies, and enrich existing knowledge about outcomes for siblings and extended family.

Children's perception of breathlessness in acute asthma

AIM

To determine whether asthmatic children who present to hospital with hypoxia perceive breathlessness less well than non-hypoxic presenters.

METHODS

A total of 27 children aged 5-16 years (mean age 10) admitted with acute asthma had recordings of oxygen saturation (SaO(2)), clinical score, forced expiratory volume in one second (FEV(1)), and breathlessness score (HMP) at admission and at 5, 10, 24, 48, and 72 hours after admission. Those defined as hypoxic (SaO(2) <92%) at admission were compared with a non-hypoxic group.

RESULTS

Twelve children were hypoxic at admission. Compared with the non-hypoxic group they were younger (8.6 (SD 2.8) v 11.2 (2. 8) y, p = 0.02), and had greater airway obstruction (FEV(1) 32.5 (10)% v 54.3 (26)%, p = 0.0073, 95% confidence interval (CI) -36.9 to -6.6) yet had a trend towards less breathlessness (median HMP 4 v 3, p = 0.062, CI -0.001 to 2.00) at admission. The hypoxic group had a smaller change in breathlessness from admission to discharge, despite a similar improvement in FEV(1), reflected in a lower ratio of change in HMP to change in FEV(1) (DeltaHMP/DeltaFEV(1)) (median DeltaHMP/DeltaFEV(1) 0.021%(-1) v 0.073%(-1), p = 0.0081, CI -0.075 to -0.016). Linear regression analysis showed a strong relation between DeltaHMP/DeltaFEV(1) and initial SaO(2) (p = 0.004, r = 0. 54).

CONCLUSIONS

Asthmatic children who present to hospital hypoxic tend to perceive themselves as less breathless than non-hypoxic children. This may predispose to a future life threatening attack.

Death from asthma: rare but real

Asthma mortality has been increasing over the past 15 years. Since the incidence of fatal asthma is rare, death is perceived as an unexpected outcome. This paper reviews the nature of asthma, and the circumstances and characteristics of patients with fatal asthma attacks. In light of these features, the emergency care of acute asthma is discussed. Recommendations for improvement of prehospital and hospital care are made. Despite optimum therapy and management, death is sometimes unavoidable.

Efficacy and cost effectiveness of inhaled steroids in asthma in a developing country

Eighty six children with troublesome wheezing were studied, in a semiprospective clinical trial with the patients acting as their own controls, to assess the efficacy and cost effectiveness of inhaled steroids. Improvement in school attendance, hospitalisations, breakthrough wheezing, and acute severe attacks were used to assess clinical efficacy. Expenditure for the family, on a cost of illness framework, before and after treatment, was used to estimate cost effectiveness. Highly significant numbers of patients showed improvement in clinical parameters, confirming efficacy. Mean monthly cost before inhaled steroid treatment was Rs 2652.33 (36.33 pounds) and Rs 449.42 (6.16 pounds) after starting treatment. The mean cost per unit satisfaction (cost utility value) which was Rs 255.54 (3.50 pounds) before starting prophylaxis came down to Rs 5.42 (0.07 pound) after starting treatment. There are no previous reports of cost-benefit assessment of inhaled steroids in childhood asthma. It is concluded that, even for developing countries with financial constraints, inhaled steroid treatment for prophylaxis of asthma is a cost effective and rational form of treatment.

Prognosis of asthma in children: a cohort study into adulthood

Fifty-six children with asthma, randomly selected from a hospital clinic, were followed prospectively for 15 years from a median age of 9-24 years of age. Four follow-ups were performed and included scoring of the frequency of wheezing, the need for medication, admissions to hospital, spirometry, skin prick tests and RAST to common inhaled allergens, and evaluation of living conditions. One patient died of asthma. The remaining 55 reported for all follow-ups. After the second follow-up at a median age of 13 years, all parameters of severity of asthma showed improvement, which was significant at the last follow-up when all subjects were more than 20 years of age. Only 16% of the subjects had been free from wheezing and medication the year prior to the last follow-up. Approximately 90% of the children had clinical allergies and positive allergy tests to pollens and danders and the majority of children retained both the allergies and the reactivity into adulthood. Reactivity to moulds and mites was less frequent (40% and 31%, respectively) and seemed to decrease in adulthood. Approximately 10% of the subjects developed neither clinical allergies nor reactivity in allergy tests. Children with atopic eczema usually retained their eczema as adults. Frequent wheezing and abnormal spirometry in childhood and early onset of asthma were associated with poorer outcome. The social prognosis was excellent.