Acute Asthma In Children Research Articles

Time trends and seasonal variation in acute childhood asthma in tropical Singapore

Asthma is an important cause of childhood morbidity in Singapore, with cumulative prevalence rising from 3.8 to 20% between 1967 and 1994 (1). It has also been ranked second, only to injuries, as the condition with the highest number of paediatric hospital discharges, and fourth amongst the conditions utilizing the highest number of bed-days (2). Annually, there are more than 3000 hospital discharges for childhood asthma in Singapore (2). Seasonal variations in hospital admissions and Accident and Emergency room (A&E) visits for asthma have been noted in many temperate countries (34), and in many instance have been an indicator of potential trigger factors in the environment (4). This study aimed to examine the trends and seasonal variation in hospital admissions and A&E visits for childhood asthma in Singapore using time-series methods.

USEFULNESS OF PEF MONITORING ON ACUTE ASTHMA ATTACK AND RECOVERY PERIOD

To evaluate the usefulness of PEF measurement on acute asthma attack in children following studies were performed.1. Initially we evaluated PEF before and after β-agonist inhalation on acute asthma attacks (n=426) in 145 asthmatic children (males 86 cases, females 59 cases, age 6 to 17years-old) at outpatient clinic in our hospital, and those episodes were divided into three groups, which were admission group (n=122), admission within 24 hrs group (n=27), and non-admission group (n=277). Mean% PEF before (after) inhaled β-agonist were significantly different between three groups, with the mean of 31.6% (47.3%), 41.0% (71.6%), and 50.5% (81.6%) respectively.2. Next, we investigated changes in % PEF and other parameters (FEV1.0, V50 and SpO2) day by day in 87 admissions due to asthma attacks with no respiratory complications such as pneumonia and atelectasis in 81 asthmatic children (male 45 cases, females 36 cases, age 6-16 years-old). Percent PEF was tended to improve more faster than % V50. Percent PEF before and after inhalation of β-agonist on the second day was 55.6% and 74.2% respectively, which were significantly higher than the first day of admission, while SpO2 on the first and second day were 94.1% and 94.1% respectively, showing no significant improvement.These results suggest that measuring PEF before and after inhaled β-agonist on acute asthma attack is useful to determine treatment plan, including prediction of exacerbation after sent home. However, not only PEF but also assessment of SpO2 and peripheral airways obstruction should be measured for evaluating the recovery from severe attacks.

Sensitization to indoor allergens and the risk for asthma hospitalization in children.

Hospitalization for asthma continues to present a major health problem despite advances in our understanding that asthma is an inflammatory disease of the bronchi and that exposure to specific allergens can induce and worsen this inflammation. The role of sensitization to specific indoor allergens and hospitalization for acute asthma in children is unclear. The purpose of this study was to evaluate the independent contributions of sensitization to specific indoor allergens among children with asthma to the risk of hospitalization for asthma. The charts of 138 consecutive children with asthma, aged 5 to 18 years, seen at pediatric allergy clinics were reviewed to obtain the results of skin tests to cat, dog, cockroach, and dust mite allergens and the history of hospitalization for asthma within the year prior to the clinic visit. Logistic regression analysis was used to examine the association between indoor allergen sensitivity and other factors, and the risk of hospitalization for asthma. In univariate analyses, hospitalization for asthma was significantly associated with cockroach sensitivity (odds ratio [OR] = 2.2; 95% confidence interval [CI] = 1.1, 4.3); cat sensitivity (OR = 2.9; CI = 1.3, 6.4); black race (OR = 2.4; CI = 1.1, 5.1); public aid/self pay (OR = 2.3; CI 1.1, 4.9) and age, (OR [per year increase in age] = 0.8; CI = 0.7, 0.9). In a stepwise multiple logistic regression analysis, only cat sensitivity (OR = 3.8; CI = 1.5, 9.2), age (OR = 0.8; CI = 0.7, 0.9) and race (OR = 3.2; CI = 1.4, 7.5) entered into the model as significant independent predictors. Sensitivity to cat allergen may be an important determinant for asthma hospitalization in children. Sensitization to cockroach allergen per se was not found to be an independent risk factor. As observed in previous studies, younger and black children were at increased risk of hospitalization for asthma.

Management of acute asthma in children

Management of acute asthma in children

Reduction in length of hospital stay for acute childhood asthma associated with the introduction of casemix funding

To examine changes to hospital admission rates, length of stay (LOS), bed use, and unplanned readmission rates for children with acute exacerbations of asthma following the change of the Victorian health care system to casemix funding. Large university-affiliated children's hospital in Melbourne, Victoria. Prospective collection of data from July 1989 to June 1996 for all children admitted with acute asthma (n = 11939). The number of admissions for acute asthma showed a rising trend before the introduction of casemix funding in July 1993, and subsequently fell. There was a significant fall in mean LOS (64.5 to 39 hours; -40%; P = 0.001), and hence in bed-hours occupied for asthma (115370 to 61116; -47%; P = 0.001). There were no increases in unplanned readmission rates for asthma within the next seven or 14 days. LOS and bed use for acute asthma at our hospital have been significantly reduced since the introduction of casemix funding, although this study does not prove a causal relationship. There was no increase in readmission rates, and thus no suggestion of any adverse effects as a result of reducing LOS. The 47% reduction in bed-hours should lead to large reductions in cost to the hospital.

Reduction in length of hospital stay for acute childhood asthma associated with the introduction of casemix funding

Reduction in length of hospital stay for acute childhood asthma associated with the introduction of casemix funding

Descriptive epidemiology of asthma

Descriptive epidemiology of asthma

Factors related to severe acute asthma in childhood - epidemiologic and clinical aspects

To study the epidemiologic and clinical factors related to severe acute asthma in patients hospitalized in pediatric intensive care unit (PICU). STUDY PROFILE: Prospective, epidemiologic. All admissions were observed. All children with severe asthma admitted to PICU-HSL-PUCRS between January, 1994, and December, 1994. Their parents were asked to answer a questionnaire about clinical history and precipitating factors of bronchospasm. Clinical evolution was observed in each patient. 31 children were admitted on 42 occasions to the PICU for the treatment of severe asthma (7.3% of all admissions). The male: female ratio was 1.2:1.0 and the age mean was 25 months. Respiratory viral infections were the main precipitating factor of asthma attacks (74%). Family history of asthma, atopy or tabagism were observed in 97% of the cases. A longer hospitalization period was associated with less than 1 year age (p=0.0005), family history of tabagism (OR= 2.3) and occurrence of pneumonitis (p= 0.03). The long stay in PICU was associated with previous PICU admission (p=0.03), family history of tabagism (OR=2.0) and occurrence of pneumonitis (p=0.02). The main complication observed, especially in patients under 1 year receiving public health care, was pneumonitis, that was diagnosed in 42% of these children. Patients assisted by a private doctor had a shorter hospitalization period and less pneumonitis complication. Mechanical ventilation was necessary in 10% of these patients. There was no death in our series. The incidence of severe acute asthma, associated with long staying in PICU and hospitalization, is related to low age (under 1 year), previous hospitalization due to bronchospasm, family history of asthma, atopy or tabagism, and ineffective medical care. These factors seem related to frequent crises causing more hospitalization indications. These children frequently present pneumonitis during their clinical evolution. Early and aggressive management in general benefit the clinical course of severe acute asthma. The mortality ratio for children with acute asthma who need PICU admissions is small.

Management of acute asthma in children.

AimThe aim of this article is to update the reader’s knowledge of the management of acute exacerbations of childhood asthma.

Reduction in length of hospital stay for acute childhood asthma associated with the introduction of casemix funding

Objective To examine changes to hospital admission rates, length of stay (LOS), bed use, and unplanned readmission rates for children with acute exacerbations of asthma following the change of the Victorian health care system to casemix funding. Setting Large university-affiliated children's hospital in Melbourne, Victoria. Design Prospective collection of data from July 1989 to June 1996 for all children admitted with acute asthma (n= 11 939). Results The number of admissions for acute asthma showed a rising trend before the introduction of casemix funding in July 1993, and subsequently fell. There was a significant fall in mean LOS (64.5 to 39 hours; -40%; P=0.001), and hence in bed- hours occupied for asthma (115370 to 61116; -47%; P=0.001). There were no increases in unplanned readmission rates for asthma within the next seven or 14 days. Conclusion LOS and bed use for acute asthma at our hospital have been significantly reduced since the introduction of casemix funding, although this study does not prove a causal relationship. There was no increase in readmission rates, and thus no suggestion of any adverse effects as a result of reducing LOS. The 47% reduction in bed-hours should lead to large reductions in cost to the hospital.

Ultrasonic Nebulization of Albuterol is No More Effective Than Jet Nebulization for the Treatment of Acute Asthma in Children

Nebulizer systems used to generate therapeutic aerosols vary in their ability to deliver medication to the airway. In a recent study in 17 adults with stable asthma, albuterol given using an ultrasonic nebulizer (UN) appeared to produce greater bronchodilatation than the same dose of albuterol given by a jet nebulizer (JN). The purpose of this study was to determine if the UN used in that study would produce a better bronchodilator response in children with acute asthma than the JN system that has been in use at Cardinal Glennon Children's Hospital. Randomized, prospective, unblinded study. An urban university children's hospital emergency department. One hundred thirteen children, aged 7 to 16 years, who presented for treatment of acute moderately severe asthma completed this study. After randomization and exclusion of dropouts, 46 children received albuterol by UN and 67 were treated by JN. Pulmonary function tests (PFTs) by spirometry, pulse oximetry, and symptom score at baseline and at 15 and 30 min following a single prescribed treatment. PFT on entry to the study was the same in both groups (FEV1; p>0.97). The change in FEV1 after therapy (UN+0.22 L vs JN+0.37 L) was significant (p<0.05) and favored JN. There was no difference in the improvement in pulmonary function between JN and UN therapy in children with an initial FEV1/FVC > 75% predicted but when FEV1/FVC < 75%, the improvement in FEV1 again favored the JN (UN+0.2 vs JN+0.47; p<0.05). For the treatment of acute exacerbations of asthma in children, there is no greater bronchodilator response when albuterol is administered by a UN than by a JN.

Current controversies in acute paediatric asthma

A lively debate regarding the administration of ipratropium bromide in acute childhood asthma, and the use of inhaled corticosteroids as first-line preventive therapy, took place during the recent International Paediatric Respiratory Congress [Sydney, Australia; March 1997].

Randomised trial of intravenous salbutamol in early management of acute severe asthma in children

The mainstay of treatment for acute asthma in children is nebulised beta 2-adrenergic agents such as salbutamol, given with corticosteroids. However, penetration of the drug to the small airways is impeded by obstruction so intravenous salbutamol may be more effective. We assessed the use of intravenous salbutamol in the management of children with acute severe asthma in a double-blind randomised study. Children who presented to the Emergency Department of Westmead Hospital, Sydney, Australia with asthma were assessed with a clinical assessment scale, and those with severe acute asthma were given nebulised salbutamol at a dose of 2.5 mg (age < or = 2 years) or 5.0 mg (age > 2 years), made up to 4 mL with saline. Children who did not improve were eligible to enter phase one of the study. In this phase (0 h-2 h) treatment was by a standard protocol: nebulised salbutamol at the above dose: 4 L/min or 6 L/min continuous oxygen until oxygen saturation reached 93% in room air for at least 30 min; a bolus of intravenous hydrocortisone 5 mg/kg given over 3 min; and then 15 micrograms/kg intravenous salbutamol or saline, depending on randomised allocation. In phase two (2 h-24 h) the children were given nebulised salbutamol continuously then at 30 min, 1 h, 2 h, 3 h, and 4 h, according to need. All children were transferred to the ward once they were ready to start hourly nebulisation. All patients were followed up until discharge. The primary endpoints were recovery time (no longer requiring inhaled salbutamol) and persistent moderate to severe asthma 2 h after randomisation. Analyses were by intention-to-treat although no withdrawals occurred. The recovery time (time to cessation of nebulised salbutamol every 30 min) was 4 h in the 14 children allocated intravenous salbutamol compared with 11.5 h for the 15 children in the control group. 2 (14%) of the intravenous salbutamol group compared with 8 (53%) of the control group needed oxygen to maintain oxygen saturation at 93% room air. The intravenous salbutamol group were ready for discharge from the emergency department 9.7 h earlier than the control group. No clinically significant side-effects were found in either group. Addition of a 10 min infusion of salbutamol in the early treatment of children with acute severe asthma has the potential to curtail the clinical progression of asthma, reduce demand placed on hospital resources, and improve the quality of health care provided to the acutely sick child with asthma.

Intravenous Versus Oral Corticosteroids in the Management of Acute Asthma in Children

Study objective: To determine whether oral corticosteroids are significantly better at preventing the need for hospital admission than IV corticosteroids in children with moderate to severe asthma exacerbation. Methods: We carried out a randomized, double-blind, controlled trial of patients in the emergency department of a tertiary urban children's hospital. Patients who presented to the ED with moderate to severe asthma (defined as forced expiratory volume in 1 second [FEV 1] < 60% predicted for height in patients aged 7 to 18 years and as Pulmonary Index Score [PIS] between 6 and 11 for patients aged 18 months through 6 years). Patients were randomized to receive 2 mg/kg oral methylprednisolone or 2 mg/kg IV methylprednisolone 30 minutes after the initial treatment with nebulized albuterol. Each patient was otherwise treated with an identical regimen of frequent nebulized albuterol and IV theophylline for a total of 4 hours. Results: Forty-nine patients were enrolled. Four hours after treatment, both groups had similar respiratory rates, oxygen saturation, PISs, and FEV 1 values. Eleven of 23 patients in the oral group (48%) and 13 of 26 patients in the IV group (50%) were admitted to the hospital ( P=.88). The 90% confidence interval for the 2% difference in admission rate to the hospital (favoring oral methylprednisolone) ranged from 21% (favoring IV methylprednisolone) to 25% (favoring oral methylprednisolone). Patients discharged home demonstrated greater improvement from baseline with regard to PIS and FEV 1 than patients who were admitted. Two patients in each group failed to complete the standard treatment or returned to the hospital within 48 hours of ED discharge. Conclusion: These data suggest that for children with moderate to severe asthma exacerbation, hospital admission rates are similar in children given oral methylprednisolone and those given IV methylprednisolone. [Barnett PLJ, Caputo GL, Baskin M, Kuppermann N: Intravenous versus oral corticosteroids in the management of acute asthma in children. Ann Emerg Med February 1997;29:212-217.]

Evaluation of pre- and posttreatment pulse oximetry in acute childhood asthma.

To evaluate the utility of pre- and posttreatment O2 saturation (SpO2) for prediction of admission or relapse after ED release in acute asthma exacerbations using a standardized treatment protocol. A prospective, double-blind, observational study was performed at a pediatric ED. Children with acute asthma were enrolled upon ED presentation. SpO2 was measured prior to treatment and after disposition decision. Two experienced physicians determined disposition based on history and physical examination alone, while blinded to SpO2. Relapse of released patients was determined by telephone follow-up. A pretreatment room-air SpO2 of < or = 91% had a sensitivity of 0.24, a specificity of 0.86, and a likelihood ratio of 1.77 to predict admission/relapse. A posttreatment room-air SpO2 of < or = 91% had a sensitivity of 0.34, a specificity of 0.98, and a likelihood ratio of 16.43 to predict admission/relapse. As opposed to some previous studies, this study found pretreatment SpO2 to be a relatively poor predictor of admission. A posttreatment SpO2 of < or = 91% occurred in a minority (32%) of patients, but increased the odds of admission 16-fold and may be used as an adjunct to objectively confirm the need for admission.

Acute Asthma Therapy

A reader noted: "I am surprised to find no mention of inhaled steroids in the article by Drs. Murphy and Kelly `Advances in Management of Acute Asthma in Children' (July 1996). Their article is the only one I have come across that avoids mentioning the use of inhaled corticosteroids in children during the last 4 to 5 years when there seems to be a concerted effort to get pediatricians to use them." Drs. Kelly and Murphy respond: "We appreciate your concerns about our lack of discussion of inhaled corticosteroids. However, our charge for the article was to review the current treatment of acute exacerbations of asthma, including exercise-induced bronchospasm.

Allergen-specific IgE levels and mite allergen exposure in children with acute asthma first seen in an emergency department and in nonasthmatic control subjects

BACKGROUND: Sensitization to allergens has been shown to be a risk factor for adults with acute asthma first seen in the emergency department. OBJECTIVE: The purpose of this study was to evaluate the prevalence of specific IgE to common aeroallergens in children with asthma first seen in the emergency department and in control subjects. METHODS: Fifty-four children, aged 3 to 16 years (mean age, 8.34 years) who visited the emergency department for treatment of acute bronchospasm or other illness, were evaluated. Specific IgE to seven common aeroallergens and four common storage mites was determined. Group I consisted of 29 patients who had acute bronchospasm and histories of recurrent asthma. Group II consisted of 25 control subjects who had no clinical history of atopic disease. Groups I and II were compared for differences in the prevalence of positive RAST responses to the 11 allergens tested. Dust samples were collected from 17 homes of subjects in group I and from 13 homes of subjects in group II and were analyzed for levels of Der p 1 and Der f 1. RESULTS: Statistically significant differences in the prevalence of positive RAST results between groups I and II were found in response to: Dermatophagoides pteronyssinus, 89.6% versus 36% ( p = 0.0001); Blattella germanica, 45.8% versus 9.5% ( p = 0.018); Alternaria tenuis, 44.8% versus 4% ( p = 0.001); and the storage mites Aleuroglyphus ovatus, 39.2% versus 4% ( p = 0.002); Blomia tropicalis, 42.8% versus 0% ( p = 0.0002); Chortoglyphus arcuatus, 46.4% versus 0% ( p = 0.0001); and Lepidoglyphus destructor, 32.1% versus 0% ( p = 0.0019). Mean specific IgE levels, expressed as percent of the total counts bound, were significantly higher in group I compared with group II only in response to D. pteronyssinus, 21.9% versus 2.1% (mean percent of total counts bound) ( p = 0.0001). Analysis of dust samples revealed no significant differences between the two groups, except for a higher concentration of Der f 1 in the sofas of subjects in group II. CONCLUSION: Sensitization to D. pteronyssinus, storage mites, and, to a lesser extent, to A. tenuis and B. germanica is associated with acute childhood asthma that requires emergency treatment in Florida. (J Allergy Clin Immunol 1996;98:258-63.)

Advances in the management of acute asthma in children.

In 1991, the National Heart, Lung and Blood Institute9s National Education Program (NAEP) published Guidelines for the Diagnosis and Management of Asthma recommended by an expert panel. This was followed in 1992 by the publication of the Internal Consensus Report on Diagnosis and Management of Asthma (ICR). These reports reviewed the current state of knowledge and established the goals of therapy for both chronic asthma and acute exacerbations. This article will provide an update on the research that has been published since those recommendations. The first NAEP guidelines established three goals for the treatment of acute asthma: Rapid reversal of airflow obstruction, correction of significant hypoxemia, and reduction of the rate of recurrent severe asthma symptoms. The ICR added two additional goals: Restoration of lung function to normal as soon as possible and development of a written plan of action in case of a further exacerbation. Both reports concluded that these goals could be accomplished best by aggressive use of inhaled selective beta 2 -agonists and early introduction of systemic corticosteroids (in certain patients at home). The liberal use of low-flow oxygen was considered safe; it often easily corrects the hypoxemia produced by the alveolar hypoventilation and the mismatch in ventilation/perfusion (V/Q) that frequently accompanies acute asthma exacerbations.

Advances in the Management of Acute Asthma in Children

In 1991, the National Heart, Lung and Blood Institute's National Asthma Education Program (NAEP) published "Guidelines for the Diagnosis and Management of Asthma" recommended by an expert panel. This was followed in 1992 by the publication of the "Internal Consensus Report on Diagnosis and Management of Asthma" (ICR). These reports reviewed the current state of knowledge and established the goals of therapy for both chronic asthma and acute exacerbations. This article will provide an update on the research that has been published since those recommendations. The first NAEP guidelines established three goals for the treatment of acute asthma: Rapid reversal of airflow obstruction, correction of significant hypoxemia, and reduction of the rate of recurrent severe asthma symptoms. The ICR added two additional goals: Restoration of lung function to normal as soon as possible and development of a written plan of action in case of a further exacerbation. Both reports concluded that these goals could be accomplished best by aggressive use of inhaled selective beta2-agonists and early introduction of systemic corticosteroids (in certain patients at home). The liberal use of low-flow oxygen was considered safe; it often easily corrects the hypoxemia produced by the alveolar hypoventilation and the mismatch in ventilation/perfusion (V/Q) that frequently accompanies acute asthma exacerbations.

Theophylline in acute childhood asthma: a meta-analysis of its efficacy.

Although theophylline is a widely used drug for the treatment of acute childhood asthma, its efficacy has not been clearly established. This study constitutes a meta-analysis of published randomized clinical trials of theophylline in children hospitalized with acute asthma. We conducted a search of English language MEDLINE citations from 1966 to 1995 and analyzed the methods of each report meeting study criteria. We pooled similar clinical measures across studies if a test for homogeneity of effect size was non-significant. The six methodologically acceptable randomized clinical trials included a total of 164 children less than 18 years of age. Incomplete reporting of measures and variances was common. No study included children in intensive care settings. Using pooled results, pulmonary function parameters [forced expired volume in 1 second (FEV1), forced expired flow (FEF)] appeared better at 24 hours in the theophylline group, but the results did not reach statistical significance (mean effect difference, + 3.9% predicted values; pooled effect size, + 1.6 SDS; P = 0.25). A mean of 2.1 more albuterol treatments were administered in the theophylline group (pooled effect size, - 0.18 SDS; P = 0.02), and the mean hospital stay was slightly longer (mean effect difference, - 0.31 days; pooled effect size, - 0.18 SDS; P = 0.03). We conclude that currently available data do not indicate a significant beneficial effect of theophylline in children hospitalized with acute asthma. There is evidence for weak detrimental effects. Theophylline efficacy in intensive care unit settings remains unstudied.