International perspective on research priorities and outcome measures of importance in the care of children with acute exacerbations of asthma: a qualitative interview study

Analysis of the asthma scores recommended in guidelines for children presenting to the emergency department: a Pediatric Emergency Research Networks study

RATIONALE

While there are numerous published paediatric asthma scores, it is unknown how commonly scores are recommended in asthma guidelines across different geographical regions globally, and what their validation status is.

OBJECTIVES

(1) To describe which clinical guidelines recommend asthma scores across different geographical regions. (2) To describe the initial and subsequent validation of the commonly recommended asthma scores.

METHODS

Observational study of asthma scores recommended in guidelines for the management of acute paediatric asthma from institutions across the Pediatric Emergency Medicine Network; global paediatric emergency medicine research network comprising all eight local and regional paediatric emergency medicine research networks.

MAIN RESULTS

158 guidelines were identified. Overall, 83/158 (53%) guidelines recommend a bedside clinical score for assessment of asthma severity. While a single country-specific clinical score was recommended in all guidelines from Spain and Canada, 27/28 (96%) of the USA guidelines recommend a wide variety of scores, and scores are rarely recommended in guidelines from other research networks (PERUKI, Paediatric Emergency Research in the UK and Ireland and PREDICT, Paediatric Research in Emergency Departments International Collaborative in Australia and New Zealand) and other countries (Costa Rica, South Africa, Nigeria, Singapore, India).The Pediatric Respiratory Assessment Measure (PRAM) and the pulmonary score (PS) were the most frequently used scoring instruments. While the PRAM has undergone the most extensive validation, including construct validity, validation studies for the PS are limited. Inter-rater reliability, as well as the criterion, responsiveness and discriminative validity aspects represent the most common limitations in many of the scores.

CONCLUSIONS

There are marked geographical differences in both the recommendation for and the type of clinical asthma score in clinical practice guidelines. While many asthma scores are recommended, most have insufficient validation.

Intravenous Magnesium: Prompt use for Asthma in Children Treated in the Emergency Department (IMPACT-ED), a pilot randomized trial

BACKGROUND

Asthma is the most common chronic illness of childhood and a leading cause of hospitalization and health care costs for children. Intravenous magnesium sulfate (IVMg) may help severely ill children avoid hospitalization when added to standard treatment in an emergency department (ED), but this has not been adequately evaluated in a large trial. We conducted a pilot trial to test procedures and gather information to plan a large multicenter trial.

METHODS

Children 2-17 years old with severe acute asthma were randomized in a multicenter, double-blind, controlled trial of placebo (saline, 1 mL/kg, max 40 mL), low-dose IVMg (50 mg/kg, max 2 g), or high-dose IVMg (75 mg/kg, max 3 g) in addition to standard asthma therapy at the EDs of three tertiary pediatric hospitals between September 2022 and May 2023. We assessed the feasibility of delivering study drug within 90 min of treatment (defined as the start of the first inhaled albuterol) and monitoring for hypotension and obtained blood samples for pharmacologic analysis. Our target enrollment was one participant per site per week (90 total).

RESULTS

A total of 52 patients were randomized, and 49 received study drug. Median (Q1, Q3) participant age was 6.3 (4.6, 9.6) years and 35 (67.3%) were male. Among 52 randomized participants, study drug was delivered within 90 min to 34 (65.4%), 486/542 (89.7%) anticipated blood pressure measurements were within time frames, 138/156 (88.5%) anticipated blood samples were obtained, and 38 (73.1%) were hospitalized. Hypotension was measured within 2 h of study drug administration in 2/18 (11.1%) who received placebo and 2/31 (6.5%) who received IVMg.

CONCLUSIONS

Most anticipated blood pressure measurements and blood samples were obtained. Hypotension occurred at rates similar to previous reports. Lower-than-expected enrollment (related to low patient volumes) and timely delivery of study drug will require consideration for a larger trial.

Pharmacokinetics and Pharmacodynamics of Intravenous Magnesium Sulfate in Pediatric Acute Asthma Exacerbations

Pediatric asthma exacerbations represent a significant cause of emergency department use and hospitalizations. Despite available treatment options, many children's exacerbations are refractory to standard therapies and require adjunct treatments. The Intravenous Magnesium: Prompt use for Asthma in Children Treated in the Emergency Department study investigated the pharmacology of intravenous magnesium sulfate (IVMg) in treating pediatric asthma exacerbations. Specifically, the objectives of the study included (1) externally validating a previously published population pharmacokinetic model and (2) linking serum magnesium concentrations with outcomes including asthma severity score (efficacy) and hypotension (safety). Data were obtained from 49 children prospectively treated with IVMg (placebo, 50 or 75 mg/kg) after presenting to the pediatric emergency department with an acute asthma exacerbation. Reductions in Pediatric Respiratory Assessment Measure scores were associated with both total and ionized serum magnesium area under the concentration-time curve (AUC0-2 h). Despite frequent study-specific blood pressure monitoring, hypotension was uncommon in IVMg-treated participants (n = 2/31), and no concentration dependence was observed. The findings signal that IVMg may be an efficacious and safe option for treating moderate-severe pediatric acute asthma exacerbations in the ED. Importantly, this study is the first to suggest a serum exposure target (total serum magnesium AUC0-2 h >63.1 mg h/L) reflective of effective IVMg dosing in pediatric acute asthma. While further study in a larger clinical trial is needed to refine and validate this exposure target, these findings support the continued study of IVMg therapy as an adjunct therapeutic option in the setting of pediatric asthma exacerbations.

Global respiratory health priorities at the beginning of the 21st century

Respiratory health has become a prevailing priority amid the diverse global health challenges that the 21st century brings, due to its substantial impact on individuals and communities on a global scale. Due to rapid advances in medicine, emerging knowledge gaps appear along with new challenges and ethical considerations. While breakthroughs in medical science can bring about encouraging possibilities for better treatments and interventions, they also lead to unanswered questions and areas where further research is warranted. A PubMed search on the topic "global respiratory health priorities" between the years 2000 and 2023 was conducted, which returned 236 articles. Of these, 55 were relevant and selected for inclusion in this article. The selection process took into account literature reviews, opinions from expert groups and careful analysis of existing gaps and challenges within the field; our selection encompasses specific infectious and noninfectious respiratory conditions in both adults and children. The global respiratory health priorities identified were selected on the basis that they have been recognised as critical areas of investigation and potential advancement and they span across clinical, translational, epidemiological and population health domains. Implementing these priorities will require a commitment to fostering collaboration and knowledge-sharing among experts in different fields with the ultimate aim to improve respiratory health outcomes for individuals and communities alike.