Acute Asthma Exacerbations In Children Research Articles

Infections, Immunity & their Effects on Asthma

Infections, Immunity & their Effects on Asthma

Survey of Albuterol Delivery Methods in Emergency Departments for Acute Asthma Exacerbation in Children 2 Months to 15 Years

The management of pediatric bronchial asthma is often addressed by emergency department (ED) personnel. By surveying emergency program directors, we identify prevailing methods of albuterol delivery for the treatment of an acute asthma exacerbation. Because the Cochrane systematic review reports an equivalent effectiveness of the nebulizer versus metered dose inhaler (MDI) with valved holding chambers (VHC) for albuterol delivery, one might surmise that their usage would be evenly split. However, we find that within an ED setting, use of MDI with VHC sans nebulizer for acute asthma exacerbation is seldom used: 0–1% across all age groups. This is even more surprising considering the nebulizer has been shown to be more expensive than MDI with VHC. It stands to reason the promotion of national guidelines would result in potential cost savings. (Pediatr Asthma Allergy Immunol 2006; 19[3]:180–184).

Comparison of nebulized ipratropium bromide with salbutamol vs salbutamol alone in acute asthma exacerbation in children

Despite multiple doses of beta2-agonists in the treatment of acute asthma exacerbation, significant residual airways obstruction often remains. To determine whether the addition of inhaled ipratropium bromide to salbutamol provides improvement in lung function and clinical asthma symptoms in young children with acute asthma exacerbation. This study was a prospective, double-blind randomized control trial of children aged 3 to 15 years who presented with an acute asthma exacerbation at the emergency department or outpatient clinic of Thammasat University Hospital, Pathumthani, Thailand, between September 2001 and February 2003. Subjects were randomized to receive 3 doses of nebulized salbutamol mixed with isotonic sodium chloride solution (control) or ipratropium bromide (treatment) every 20 minutes. Additional doses of salbutamol were given every 30 minutes as needed. Asthma outcome measures were evaluated 40, 70, 100, and 120 minutes after baseline. Primary outcomes were the differences in percent change in asthma clinical score and percent change in peak expiratory flow rate (PEFR) from baseline. Secondary outcomes included change in percent predicted PEFR. Of 74 children randomized and enrolled in the trial, 71 had complete data for analysis. Thirty-three children were in the control group and 38 were in the treatment group. Both the percent change in PEFR and the change in percent predicted PEFR at any time were higher in the treatment group, but these findings were not statistically significantly different. The number of subjects with at least a 100% percent predicted PEFR at any time point was greater in the treatment group. Although this study did not demonstrate a significant advantage in clinical score and PEFR, the trend toward additional effect of ipratropium bromide was consistent with previous studies.

Virus Detection, Cytokine Response Profiles, and Eosinophil Activation in Acute Exacerbation of Childhood Asthma

Virus Detection, Cytokine Response Profiles, and Eosinophil Activation in Acute Exacerbation of Childhood Asthma

Broncodilatadores inhalados mediante MDI con cámara espaciadora en urgencias pediátricas: ¿cuál es la dosis?

Bronchodilators administrated through a metered-dose inhaler (MDI) with spacer are as effective as nebulizers in the treatment of acute asthma exacerbations in childhood. However, consensus is lacking on the most suitable dosage. To assess the effectiveness of distinct salbutamol and terbutaline doses delivered via an MDI with spacer for the treatment of acute asthma in the pediatric emergency department. This was a prospective, double-blind randomized study. All consecutive children (n = 324) between 2 and 14 years of age with acute asthma exacerbations treated in the pediatric emergency department between October 1 and November 30, 2004, were included. Two treatment groups were established: one group received a number of puffs equivalent to half the child's weight (1 puff of salbutamol = 100 microg and 1 puff of terbutaline = 250 microg) and the other group received a number of puffs equivalent to one-third of the child's weight. Three hundred twenty-four episodes were studied; there were 164 children in the first group and 160 in the second. There were no significant differences between the two groups in the mean (6 SD) age (58.34 +/- 34.72 vs 66.04 +/- 36.45 months), arterial oxygen saturation (95.49 +/- 1.93 vs 95.56 +/- 1.97) or pulmonary score (4.04 +/- 1.55 vs 3.97 +/- 1.51) at recruitment and after treatment in the emergency department (arterial oxygen saturation [96.34 +/- 1.60 vs 96.18 +/- 1.77], pulmonary score [1.87 +/- 1.33 vs 1.64 +/- 1.31]). The number of doses administered (2.17 +/- 0.91 vs 2.24 +/- 1.00) and the hospitalization rate (8.56 % vs 6.87 %) were also similar in both groups. The distinct bronchodilator doses administered via an MDI with spacer showed similar effectiveness. These findings should contribute to a reevaluation of the use of high doses of bronchodilators, at least in most acute asthma exacerbations in children.

Beyond our Pages

Beyond our Pages

Effects of Two Nebulization Regimens on Heart Rate Variability During Acute Asthma Exacerbations in Children

Analysis of heart rate variability (HRV) has been used to evaluate changes in sympathovagal balance. The present study was designed to investigate the influence of two therapeutic regimens on autonomic cardiovascular regulation during acute asthma exacerbations (AAE). Twenty children, 7–13 years of age, with moderate or severe AAE were randomized in two equal groups to receive either 0.15 mg/kg/dose salbutamol (group 1) or a combination of lower-dose salbutamol (0.10 mg/kg/dose) and ipratropium bromide (5 mcg/kg/dose) (group 2). Exacerbations were treated with three nebulizations (Tx) of either regimen given 20 minutes apart. HRV indices [total power, high-frequency component (HF), low-frequency component (LF), and LF:HF ratio] were analyzed at specific time intervals during the management of AAE. Therapy had a significant time-dependent main effect on total power (p = 0.001), LF (p < 0.0001), and HF (p = 0.005) but reached only borderline significance for LF:HF ratio (p = 0.053). The decrease in LF was more pronounced in group 2 vs. group 1 at 10 minutes post-Tx1 (p = 0.034) and at 10 minutes post-Tx2 (p = 0.05), but there was no significant difference between groups at 10 and 20 minutes post-Tx3. There were no significant differences between groups in any of the other HRV indices. Both regimens improved FEV1 (p = 0.0001) to the same magnitude. During AAE, three consecutive inhalation treatments with either high-dose salbutamol-only or lower-dose salbutamol plus ipratropium bromide combination, resulting in similar FEV1 improvement, cause domination of sympathetic over parasympathetic nervous system of similar overall magnitude but distinct patterns of HRV indices.

Comparison of nebulized ipratropium bromide with salbutamol versus salbutamol alone in acute asthma exacerbation in children

Comparison of nebulized ipratropium bromide with salbutamol versus salbutamol alone in acute asthma exacerbation in children

HUBUNGAN ANTARA DERAJAT OBSTRUKSI SALURAN NAFAS SERANGAN AKUT ASMA DENGAN JUMLAH SEL-SEL INFLAMASI DARAH TEPI

There now exists compelling evidence of a role for  cell-mediated immunity in the pathogenesis of asthma, but little information is available as to what extent this process participates in the disease severity. The hypothesized of this reseach that the severity of acute asthma exacerbation in children is associatedwith the activation of T-lymphocytes whose products regulate, at least in part, the mobilization and recruitment of eosinophyls and thereby disease severity. The aims of this research, therefore, were to compare the peripheral blood T-lymphocytes from acute asthmaticand no asthmatic normal control children matched for age and sex, and to attempt to correlate the percentages of T-lymphocytes in the asthmatic with the numbers of peripheral  blood eosinophyls and with disease severity. Fifty one children with acute asthma exacerbation were compared with thirty one no asthmatic, normal children matched for age and sex. Peripheral blood CD4+ and  CD8+ T-lymphocytes was measured using immuno histochemical staining. Peripheral blood eosinophils were measured using anautomated laser cytometer. Asthma exacerbation severity was assessed by a symptom score and spirometri. The absolute numbers  of eosinophils and CD4+ T-lymphocytes of the asthmatic were elevated as compared to the non-asthmatic normal control, whereas the numbers of CD8+ T-lymphocyte decreased significantly.

Early intervention with increased inhaled corticosteroids (ICS) for controlling of acute asthma exacerbations improves outcomes

Rationale This study investigates the effectiveness of early intervention with increased dosing of ICS in controlling acute asthma exacerbations in children at home. Methods Records of 100 children with acute exacerbation of asthma at home were reviewed. Study population consisted of children with mild to moderate persistent asthma aged 1-18 years. Exacerbations were divided into those with symptoms less than 72 hours prior to initiation of treatment (Group I) and those greater than 72 hours (Group II). Outcomes with increased ICS in both groups were evaluated for symptom resolution verses subsequent oral steroid use. Results 100 patients with a mean age 7.8yr yielded 63 acute asthma exacerbations. 46 of these were treated with increased dosing of ICS, mean increase 400ug of fluticasone or 800ug of budesonide (from their base line doses). 32 of these (70%) had treatment initiated within 72 hours of onset of symptoms (Group I). Complete resolution of symptoms was achieved and only 6% (2/32) of these required oral steroids. However 36% (5/14) children in Group II not only required oral steroid but there was also delay in clinical improvement. This improved outcome was seen most dramatically in the mild persistent asthmatics (0% vs. 30%) and the moderate persistent asthmatics (11% vs. 50%). Conclusions Increasing ICS within 72 hours of onset of symptoms in an acute asthma exacerbation improves outcomes as measured by symptom resolution as opposed to subsequent oral steroid use.

The Effectiveness of High-Dose Inhaled Budesonide Therapy in the Treatment of Acute Asthma Exacerbations in Children

Purpose of the Study. The purpose of this study was to evaluate the efficacy of high-dose inhaled budesonide, in comparison to oral methylprednisolone, in the treatment of acute asthma exacerbations in children. Study Population. Sixty children, ages 4 to 17 years, who had experienced an acute asthma exacerbation over a period of 6 months. All patients met the American Thoracic Society criteria for asthma. Methods. Children who experienced an acute asthma attack unresponsive to home management, yet not severe enough to be hospitalized, were randomized into 2 groups. Group 1 received high-dose inhaled budesonide (1600 μg daily) plus dry powder terbutaline (2000 μg daily). Group 2 received oral methylprednisolone (1 mg/kg/day) plus …

Infections and asthma in children.

The temporal association of acute asthma exacerbations in children with viral infections such as rhinovirus, respiratory syncytial virus, and parainfluenza has been known for many years. Recently, the contributions of infections to the pathophysiology of asthma have been expanded beyond disease exacerbation to include disease inception, chronicity, and even prevention. Respiratory syncytial virus has been implicated in asthma inception, while Chlamydia pneumoniae, Mycoplasma pneumoniae, and latent adenovirus infections have been correlated with asthma chronicity. Measles, hepatitis A, and tuberculosis have been associated with a decreased incidence of asthma, implying a contribution to disease prevention. The following review will briefly highlight the relationships between various microbial infections and the pathophysiology of asthma.

Provider adherence to a clinical practice guideline for acute asthma in a pediatric emergency department.

Critics of the use of clinical practice guidelines (CPGs) in an emergency department (ED) setting believe that they are too cumbersome and time-consuming, but to the best of the authors' knowledge, potential barriers to CPG adherence in the ED have not been prospectively evaluated. To measure provider adherence to an ED CPG based on National Asthma Education and Prevention Program (NAEPP) recommendations, and to determine factors associated with provider nonadherence. Prospective, cohort study of children aged 1-18 years with the diagnosis of an acute exacerbation of asthma who were seen in a pediatric ED and requiring admission, as well as a random selection of children discharged to home following pediatric ED care. The following adherence parameters were assessed: at least three nebulized albuterol treatments in the first hour; early steroid administration (after the first nebulizer treatment); clinical assessments using pulse oximetry and peak expiratory flow (PEF) (for children >6 years old); and use of a clinical score to assess acute illness severity (Asthma Severity Score). Nonadherence was defined as any deviation of the above parameters. Between July 1, 1998, and June 30, 1999, 369 patients were studied. Of these, 38% (139) were discharged to home, 38% (140) were admitted to the observation unit, and 24% (90) were admitted to the inpatient unit. Illness severities at initial presentation to the ED were: 24% (86) had mild exacerbations, 59% (212) had moderate exacerbations, and 17% (62) had severe exacerbations. Sixty-eight percent (95% CI = 63% to 73%) of the patients were managed with complete adherence to the CPG. Of the 32% with some form of nonadherence, most (63%) were children older than 6 years; in this group 64% (48/75) were nonadherent due to lack of PEF assessment. When PEF assessment was disregarded, an 83% (95% CI = 79% to 87%) adherence to the CPG was achieved. Other nonadherence factors included: lack of at least three nebulized albuterol treatments provided timely within the first hour (5%); delay in steroid administration (6%); lack of pulse oximeter use (0.5%); and failure to record clinical score to assess severity (1.1%). Patient age, illness severity (acute and chronic), first episode of wheezing, and high ED volume periods (evenings and weekends) did not worsen adherence. Clinical practice guidelines can be used successfully in the pediatric ED and provide a more efficient management and treatment approach to acute exacerbations of childhood asthma. With a systematic and concise CPG, barriers to adherence in a pediatric ED appear to be minimal, with the exception of using PEF in the routine ED assessment.

The effectiveness of high-dose inhaled budesonide therapy in the treatment of acute asthma exacerbations in children

International guidelines recommend the use of systemic steroids for the treatment of acute asthma attack if it has not been resolved within 24 to 36 hours of home management with regular beta2 mimetic inhalation. Such therapy for infrequent exacerbations is unlikely to have serious systemic effects. Unfortunately, many patients receiving frequent courses are potentially at risk for corticosteroid-induced side effects such as adrenal suppression, depression of linear growth, and osteoporosis. To decrease the use of frequent oral corticosteroid courses in children, this study was designed to evaluate the efficacy of high-dose inhaled steroids in comparison with oral steroids, in the therapy of acute asthma exacerbations in children. Sixty children who have experienced an acute exacerbation of asthma unresponsive to home management with regular use of inhaled beta2 mimetics, yet not severe enough to hospitalize, were randomized to be treated with either high-dose inhaled budesonide (1,600 microg daily) or oral methylprednisolone (1 mg/kg daily) plus medium-dose inhaled budesonide (800 microg daily, both in addition to inhaled terbutaline, 2,000 microg daily). Pre- and posttreatment pulmonary index scores, forced expiratory volume in one second (FEV1), forced vital capacity (FVC), FEV1/FVC and forced expiratory flow 25% to 75% (FEF25%-75%) were evaluated. The mean number of decrease in pulmonary index score was 2.61 +/- 1.12 in the high-dose budesonide-receiving group (group I) and 1.90 +/- 1.08 in the oral steroid-receiving group (group II). There was a statistically significant difference between the two groups, in favor of group I (P = .038). No statistically significant difference was detected between the two groups with respect to the increase in lung function test measurements (FEV1, FEV1/FVC, FEF25%-75%; P = .790, .959, .819, respectively). Short-term high-dose budesonide therapy can be considered an alternative for children who are experiencing an acute asthma attack that is unresponsive to home management with regular use of an inhaled beta2 mimetic, yet who are not severe enough to hospitalize.

Does influenza vaccination prevent asthma exacerbations in children?

Objective: Influenza can exacerbate asthma, particularly in children. The effectiveness of influenza vaccine in preventing influenza-related asthma exacerbations, however, is not known. We evaluated influenza vaccine effectiveness in protecting children against influenza-related asthma exacerbations. Study design: We conducted a population-based retrospective cohort study with medical and vaccination records in 4 large health maintenance organizations in the United States during the 1993-1994, 1994-1995, and 1995-1996 influenza seasons. We studied children with asthma who were 1 through 6 years of age and who were identified by search of computerized databases of medical encounters and pharmacy dispensings. Main outcome measures were exacerbations of asthma evaluated in the emergency department or hospital. Results: Unadjusted rates of asthma exacerbations were higher after influenza vaccination than before vaccination. After adjustment was done for asthma severity by means of a self-control method, however, the incidence rate ratios of asthma exacerbations after vaccination were 0.78 (95% CI: 0.55 to 1.10), 0.59 (0.43 to 0.81), and 0.65 (0.52 to 0.80) compared with the period before vaccination during the 3 influenza seasons. Conclusions: After controlling for asthma severity, we found that influenza vaccination protects against acute asthma exacerbations in children. (J Pediatr 2001;138:306-10)

Effectiveness of inhaled corticosteroids in controlling acute asthma exacerbations in children at home.

Many clinicians advise their patients to increase the dose of inhaled corticosteroids during acute asthma exacerbations, without strong clinical evidence supporting this treatment. This study investigates the effectiveness of inhaled corticosteroids in controlling acute asthma exacerbations in children at home. The study population consisted of children with mild intermittent, mild and moderate persistent asthma aged 1 to 14 years who were treated in our outpatient clinic with inhaled budesonide for 1 year. After participating in an asthma education session, the parents were instructed to initiate treatment with inhaled budesonide at the first signs of asthma exacerbation, starting with 200 to 400 microg budesonide, in combination with beta-2 agonists 4 times a day and followed by a decrease in the dose in 4 to 8 days. Asthma status and peak expiratory flow rates were measured in the 3 monthly follow-up visits. Only children who complied with the treatment regimen and came for follow-up visits regularly were included in the final analysis. One hundred fifty children used our treatment protocol with inhaled budesonide to control their asthma attacks. Clinical improvement of asthma symptoms was achieved after a mean of 1.8 +/- 0.7 days from the beginning of treatment. The parents were able to control 94% of the 1,061 episodes of asthma exacerbation occurring during a cumulative follow-up period of 239 years. In the 3-month period before enrollment, 101 children (67%) had used oral corticosteroids to control their asthma attacks and 50 (33%) were hospitalized. During the entire follow-up period, only 11 children (7%) used oral corticosteroids, and none of the children were hospitalized. The present study demonstrates that children with asthma can control their exacerbations at home using inhaled corticosteroids (budesonide). Treatment, starting with relatively high doses followed by a rapid reduction in dose over 4-8 days, resulted in a decrease in the use of oral steroids and in hospitalization. To achieve good results, patient compliance is essential.

The Use of Ipratropium Bromide for the Management of Acute Asthma Exacerbation in Adults and Children: A Systematic Review

Ipratropium bromide is a quaternary anticholinergic bronchodilator that is commonly used to treat obstructive lung disease. Although ipratropium is not usually employed as a first-line bronchodilator to treat chronic asthma, it has been used extensively in hospital emergency departments as adjunctive therapy for the emergency treatment of acute asthma exacerbation. This review will summarize the physiological actions of ipratropium and the rationale for its use as an anticholinergic bronchodilator. Evidence available from randomized trials and from two meta-analyses is summarized to determine whether the addition of inhaled ipratropium to inhaled beta2-agonist therapy is effective in the treatment of acute asthma exacerbation in children and adults. Published reports of randomized, controlled trials assessing the use of ipratropium and concurrent beta2-agonists in adult acute asthma exacerbation were identified by a search of electronic databases, as well as by hand searching. Data from 10 studies of adult asthmatics, reporting on a total of 1377 patients, were pooled in a meta-analysis using a weighted-average method. Use of nebulized ipratropium/beta2-agonist combination therapy was associated with a pooled 7.3% improvement in forced expiratory volume in 1 sec [95% confidence interval (CI), 3.8–10.9%] and a 22.1% improvement in peak expiratory flow (95% CI, 11.0–33.2%) compared with patients who received beta2-agonist without ipratropium. For the three trials in adults reporting hospital admission data (n = 1064), adult patients receiving ipratropium had a relative risk of hospitalization of 0.80 (95% CI, 0.61–1.06). Similarly, randomized controlled studies of pediatric asthma exacerbation and a meta-analysis of pediatric asthma patients suggest that ipratropium added to beta2-agonists improves lung function and also decreases hospitalization rates, especially among children with severe exacerbations of asthma. The adult and pediatric studies did not report any severe adverse effects attributable to ipratropium when it was used in conjunction with beta2-agonists. In conclusion, there is a modest statistical improvement in airflow obstruction when ipratropium is used as an adjunctive to beta2-agonists for the treatment of acute asthma exacerbation. In pediatric asthma exacerbation, use of ipratropium also appears to improve clinical outcomes; however, this has not been definitively established in adults. It would seem reasonable to recommend the use of combination ipratropium/beta2-agonist therapy in acute asthmatic exacerbation, since the addition of ipratropium seems to provide physiological evidence of benefit without risk of adverse effects.

Does influenza vaccination exacerbate asthma? Analysis of a large cohort of children with asthma. Vaccine Safety Datalink Team.

Although influenza vaccination is recommended for children with asthma, only a minority are vaccinated. One reason for low influenza vaccine coverage among children with asthma may be concern that influenza vaccination may induce an exacerbation of asthma. To evaluate the safety of influenza vaccination in children with asthma, we studied the incidence of hospitalizations and emergency department visits for asthma following influenza vaccination. Retrospective cohort study-analysis of population-based computerized medical and vaccination records. : Four large health maintenance organizations on the West Coast of the United States. Children with asthma 1 through 6 years of age, identified by search of computerized databases of medical encounters and pharmacy prescriptions. Exacerbations of asthma. In unadjusted analyses vaccination was associated with high rates of asthma exacerbations. However, after adjusting for asthma severity using a self-control method, the incidence rate ratios of asthma exacerbations after vaccination were 0.58 (95% confidence interval, 0.36-0.95), 0.74 (95% confidence interval, 0.47-1.17), and 0.98 (95% confidence interval, 0.76-1.27) during the 3 influenza seasons. After controlling for asthma severity, we found that influenza vaccination does not result in acute asthma exacerbations in children. Concern about possible exacerbation of asthma is not a valid reason to not vaccinate children with asthma against influenza.

25 The effectiveness of high dose inhaled budesonide therapy in the treatment of acute asthma exacerbations in children

25 The effectiveness of high dose inhaled budesonide therapy in the treatment of acute asthma exacerbations in children

Management of acute asthma in children.

Aims and intended learning outcomes The aim of this article is to update the reader's knowledge of the management of acute exacerbations of childhood asthma. After reading this article you should be able to: ■ Recall the causes, incidence and treatment principles of childhood asthma ■ Recognise the signs of an acute asthmatic attack which indicate the need for referral to hospital ■ Describe the management of an acute asthmatic episode ■ Recognise the importance of consistent advice and good communication for the effective management of asthma in children.