Acute Asthma Exacerbations Research Articles

Managing Severe Acute Asthma Exacerbation in Pregnancy during the COVID-19 Pandemic: A Case Report from a Resource-limited Setting

BACKGROUND: One-third of pregnant women will experience worsening asthma requiring emergency hospitalization. However, no report comprehensively discussed the management of asthma attacks in pregnant women in impoverished settings. We attempt to illuminate what general practitioners can do to stabilize and improve the outcome of severe acute asthma exacerbations in primary care with resource limitations. CASE REPORT: A nulliparous 29-year-old woman in her 21st week of pregnancy presented severe acute asthma exacerbation in moderate persistent asthma with uncontrolled asthma status along with gestational hypertension, uncompensated metabolic acidosis with a high anion gap, anemia, respiratory infection, and asymptomatic bacteriuria, all of which influenced her exacerbations. This patient was admitted to our resource-limited subdistrict hospital in Indonesia during the COVID-19 pandemic for optimal stabilization. Crystalloid infusions, oxygen supplementation, nebulized beta-agonist with anticholinergic agents, inhaled corticosteroids, intravenous methylprednisolone, broad-spectrum antibiotics, subcutaneous terbutaline, mucolytics, magnesium sulphate, oral antihypertensives, and continuous positive airway pressure were used to treat her life-threatening asthma. After she was stabilized, we referred the patient to a higher-level hospital with more advanced pulmonary management under the supervision of a multidisciplinary team to anticipate the worst scenario of pregnancy termination. CONCLUSION: Limitations in primary care, including the lack of sophisticated intensive care units and laboratory panels, may complicate challenges in managing severe acute asthma exacerbation during pregnancy. To enhance maternal-fetal outcomes, all multidisciplinary team members should be well-informed about key asthma management strategies during pregnancy using evidence-based guidelines regarding the drug, rationale, and safety profile.

Tastes great, less filling! Randomized trial comparing perceived palatability of dexamethasone preparations in children

Dexamethasone has been shown to be effective for croup and acute asthma exacerbations in children. Current guidelines do not recommend 1 systemic corticosteroid over another, but there is some evidence to suggest dexamethasone may result in fewer gastrointestinal adverse effects. A meta-analysis aimed at determining the equivalence or superiority of dexamethasone to prednisone or prednisolone for pediatric acute asthma exacerbations found no difference in the relative risk of relapse between the 2 groups, and patients receiving dexamethasone were less likely to experience vomiting.

Nebulized Hypertonic Saline in Children with Acute Wheezing or Asthma Exacerbation: A Systematic Review and Meta-analysis

Abstract Objective: The objective of this study was to evaluate the efficacy and safety of nebulized hypertonic in children with acute wheezing or asthma exacerbation. Methods: Systematic review and meta-analysis of randomized controlled trials (RCTs) with the application of the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Relevant databases were searched till July 30, 2023. Results: Of 157 citations retrieved, two RCTs including 88 children were included in the review. A total of 38 children received hypertonic saline (HS) (5% in 16 children), and 63.6% (n = 56) were male. The RCTs included children with acute wheezing (one included acute viral wheezing) either the first episode or recurrent episodes. Compared to the control group, the nebulized HS group had a decrease in hospital stay of 1 day. The admission rate, discharge rate, and asthma severity score improved in the HS group. The evidence generated for the primary outcome (duration of hospital stay) was of “moderate certainty,” and for secondary outcomes, it varied from “very low to moderate certainty.” Conclusions: HS (3% or 5%) along with salbutamol decreased the duration of hospitalization and asthma severity score in children aged 6 months–6 years presenting with acute wheezing to the emergency department. The evidence generated was of “moderate certainty.” However, we need more data from high-quality RCTs with large sample sizes from diverse settings before any recommendation can be made. [PROSPERO registration number: CRD42022354696].

Contemporary aminophylline use for status asthmaticus in pediatric ICUs: a questionnaire-based study

Background: Status asthmaticus is severe acute exacerbation asthma that results in respiratory failure due to the failure of conventional treatment. Aminophylline is one of the methylxanthines used to manage status asthmaticus in the pediatric intensive care unit (PICU). However, aminophylline's role in managing severe asthma among children is still controversial, and PICUs still use it. There is no data on using aminophylline in Saudi Arabia. This study aimed at assessing the use and causes of using aminophylline in the PICU and the perception of pediatricians on using aminophylline in the PICU. Methods: A cross-sectional study was conducted on pediatric physicians working in PICUs employing pre-validated questionnaire. The Statistical Package for the Social Sciences program was used to analyze the retrieved data. Results: One hundred seventy-one pediatricians participated in the study; 85.4% reported IV aminophylline for acute asthma exacerbation, and 69% reported using it if the patient did not improve on other medications. About 68.4% and 83% considered IV aminophylline an effective and safe option, respectively. The side effects of IV aminophylline reported were arrhythmia at 75.3% and gastrointestinal tract side effects at 15.1%. Conclusion: Aminophylline was found highly used in PICUs in Saudi Arabia; this can be attributed to the perception of pediatricians, as it is a safe and effective treatment option.

Compare the Effectiveness of Systematic Steroids Verses Nebulizer in Pediatric Patients of Acute Exacerbation of Asthma

Aim: To compare efficacy of the nebulizer with systematic steroids in acute exacerbation of asthma patients. Study design: Prospective study Place and duration of study: Department of Pediatric Medicine, Sandeman Provincial Hospital, Quetta from 1st February 2022 to 31st July 2022. Methodology: One hundred patients with acute exacerbation of asthma and age of 1-10 years were included. Patients were divided into two groups where Group A was given flunisolide nebulization and comprised of 50 cases. The group B was given systematic steroid budesonide. The post outcomes of treatment were noted after two weeks. Results: The mean age in group A and B as 5.8±7.45 and 5.6±7.25years respectively. More boys were presented with acute exacerbation of asthma with a percentage of 66% and 68% in group A and B than girls as 34% and 32% respectively. The duration of asthma in Group A was found to be mean 3.5±6.60 years while in group B it was 4.2±4.20 years post treatment. Hospitalization was also observed at a significant higher rate in group B than Group A. Conclusion: The nebulizer has a better efficacy than systematic steroids in acute exacerbation of asthma. Keywords: Acute exacerbation, Asthma, Pediatrics, Efficacy

718: UNITED STATES TRENDS FOR AZITHROMYCIN USE IN PEDIATRIC CRITICAL ASTHMA: A MULTICENTER COHORT STUDY

Introduction: Observation reports have suggested macrolides, such as azithromycin (AZI), may be used as immunomodulation for pediatric acute asthma exacerbations. To date, few studies have described AZI use for critical asthma (CA). We sought to estimate prescribing rates of AZI for CA and identify regional and chronologic trends using a large administrative registry. Methods: We performed a multicenter, retrospective cohort study using the Pediatric Health Information Systems registry of children 3-17 years of age with CA in the pediatric intensive care units (PICUs) of 47 United States (US) children’s hospitals from Jan 2011-Dec 2020. We excluded for alternative indications for AZI (e.g., B. pertussis infection, urethritis, pelvic inflammatory disease, and atypical pneumonia). The primary outcome was prescribing rates of AZI by hospital center and calendar year (via Joinpoint regression). Cohorts with and without AZI exposure were characterized by demographics, applied CA therapies, and routine clinical outcomes using descriptive and comparative (Chi-square and Wilcoxon rank-sum) statistics. Results: Of the 32,225 children studied, 6,641 (20.6%) were prescribed AZI with a downward trend from 31.3% in 2011 to 14.7% in 2020. A Joinpoint regression indicated a linear model was ideal (-1.7% annual slope, R2 = 0.857). Regional AZI prescribing rates by hospital center varied widely with a median of 19%, interquartile range (IQR) of 13.1% to 29.5%, and total range of 4.4% to 74.5%. Compared to children without exposure, those prescribed AZI were older (median 8.3 [IQR:5.8,11.6] vs 7.4 [5,10.9] years, P< 0.001) and more severely ill with a greater rates of bilevel positive airway pressure ventilation (13.1% vs 7.3% P< 0.001), invasive ventilation (18.8% vs 11.5%, P< 0.001), extracorporeal life support (0.5% vs 0.1%, P< 0.001), and longer median length of stay (4 [IQR:3,6] vs 3 [IQR:2,4] days, P< 0.001). Conclusions: In this multicenter study assessing children hospitalized for CA in the PICU from 47 U.S. Children’s hospitals, we observed a downward AZI prescribing trend (-1.7% annually from 31.3% in 2011 to 14.7% in 2020) and wide regional variation (range: 4.4% to 74.5% by center). Prospective clinical trials are needed to assess clinical and molecular efficacy endpoints of AZI immunomodulation in pediatric CA.

Modern thromboprophylaxis protocol based on guidelines applied in a respiratory intensive care unit: a single-center prospective cohort study

BackgroundCritically ill patients in intensive care units (ICUs) are at high risk of venous thromboembolism (VTE). This study aimed to explore the prophylaxis effect under a guideline-based thromboprophylaxis protocol among critically ill patients in a respiratory ICU.MethodsFor this single-center prospective cohort study, we followed the thromboprophylaxis protocol, which was drawn up based on relevant guidelines and Chinese experts’ advice. Clinical data were entered into an electronic case report form and analyzed. Multivariate logistic regression was conducted to explore independent risk factors of VTE event under this protocol.ResultsFrom August 1, 2014, to December 31, 2020, 884 patients underwent thromboprophylaxis according to this protocol; 10.5% of them received mechanical prophylaxis, 43.8% received pharmacological prophylaxis, and 45.7% received pharmacological combined with mechanical prophylaxis. The proportion of VTE events was 14.3% for patients who received the thromboprophylaxis protocol, of which 0.1% had pulmonary thromboembolism (PTE), 2.0% had proximal deep vein thrombosis (DVT), and 12.1% had isolated distal DVT. There was no significant difference between different thromboprophylaxis measures. Cirrhosis (OR 5.789, 95% CI [1.402, 23.894], P = 0.015), acute asthma exacerbation (OR 39.999, 95% CI [4.704, 340.083], P = 0.001), and extracorporeal membrane oxygenation treatment (OR 22.237, 95%CI [4.824, 102.502], P < 0.001) were independent risk factors for proximal DVT under thromboprophylaxis.ConclusionsThe thromboprophylaxis protocol based on guidelines applied in the ICU was practicable and could help decrease the proportion of PTE and proximal DVT events. The risk factors of VTE events happening under the thromboprophylaxis protocol require more attention.Trial registrationClinicalTrials.gov: NCT02213978.

Safety and efficacy of tezepelumab vs. placebo in adult patients with severe uncontrolled asthma: a systematic review and meta-analysis

Patients with severe uncontrolled asthma still experience acute asthma symptoms and exacerbations, particularly those with non-eosinophilic inflammation who take the maximum amount of standard drug therapy. Tezepelumab, a human monoclonal antibody, can improve lung function and enhance control of asthma symptoms in those patients, regardless of the disease’s baseline characteristics. This study aims to investigate the safety and efficacy of using tezepelumab in controlling severe symptoms of uncontrolled asthma. We performed a comprehensive literature search in several databases, including PubMed, Scopus, Web of Science, Cochrane Library, and clinicaltrial.gov, using a well-established search strategy to include all relevant publications. According to our inclusion criteria, we searched for randomized controlled trials comparing tezepelumab versus placebo in patients with severe, uncontrolled asthma. We analyzed the data using The Revman 5.4 program software. The search identified 589 potential articles. After excluding studies inconsistent with selection criteria, four studies were included and analyzed qualitatively and quantitatively. The pooled effect demonstrated the better performance of tezepelumab over the placebo regarding the decrease in annualized asthma exacerbation rate (MD = − 0.74, (95% CI [− 1.04, − 0.44], p < 0.00001)), asthma control questionnaire-6 (ACQ-6) Score MD = − 0.32, (95% CI [− 0.43, − 0.21], p < 0.00001)), blood eosinophil count (MD = − 139.38 cells/mcL, (95% CI [− 150.37, − 128.39], p < 0.00001)), feNO (MD = − 10 ppb, (95% CI [− 15.81, − 4.18], p = 0.0008)) and serum total IgE (MD = − 123.51 UI/ml, (95% CI [− 206.52, − 40.50], p = 0.004)). All tezepelumab groups had higher pre-bronchodilator forced expiratory volume in 1 s than the placebo group (MD = 0.16, (95% CI [0.10, 0.21], p < 0.00001)). Higher efficacy and safety profile was detected for tezepelumab to control the exacerbations of severe uncontrolled adult asthmatics.

Effectiveness of single dose oral dexamethasone versus multidose prednisolone for treatment of acute exacerbations of asthma among children.

Asthma is one of the most common chronic diseases in children and worldwide its prevalence has increased dramatically in the last three decades. We aimed to compare single dose oral dexamethasone versus multiple doses of oral prednisolone in children with acute exacerbation of asthma in terms of post treatment requirement of systemic steroids. This Randomized control trial has been conducted in the Department of paediatrics, KRL Hospital, Islamabad from Dec 2018 to June 2019.312 patients between the age of 2-12 years patients were randomized into Group A receiving a STAT single dose of oral dexamethasone 0.3mg/kg and Group B receiving prednisolone 1mg/kg/day followed by two doses on Day 2 and 3. further dose of systemic steroids were ascertained through PRAM score. In this study mean age in Group A was 8 years with SD±5.68 while mean age in Group B was 7 years with SD±6.12. In Group A 58% patients were male and 42% patients were female. Whereas in Group B 59% patients were male and 41% patients were female. In Group A 12% patients had further requirement of systemic steroids while in Group B 18% patients had further requirement of systemic steroids while 82% patients didn't had further requirement of systemic steroids. Our study concludes that post treatment requirement of systemic steroids is less in single dose oral dexamethasone as compare to multiple doses of oral prednisolone in children with acute exacerbation of asthma.

Parents' self-reported experiences and information needs related to acute pediatric asthma exacerbations: A mixed studies systematic review.

To systematically review the scientific literature examining parents' experiences and information needs for the management of their child's asthma exacerbations. We searched five databases for quantitative and qualitative studies in Canada and the United States from 2002 onwards. A convergent integrated approach and the Mixed Method Appraisal Tool were used to analyze and appraise the evidence, respectively. We included 84 studies (27 quantitative, 54 qualitative, 3 mixed methods). Some parents lacked confidence in recognizing or managing exacerbations. A few parents were uncertain when and where to seek medical help. The main barrier to accessing care was cost. Impacts on parents included poor sleep, distress, and lifestyle disruptions. Parents felt they lacked information and wanted education on treatments and how to recognize and manage exacerbations via education sessions, written materials, community outreach and online resources. Improved education for parents may help reduce parents' stress, asthma-related morbidities for children and use of urgent health services. The development of tailored interventions and knowledge translation strategies with input from target audiences (e.g. parents, health care providers) is necessary to meet their information needs and support adherence to clinical recommendations.

Chinese expert consensus on the application of the Internet of Things as assistive technology for the diagnosis and treatment of acute asthma exacerbations

Chinese expert consensus on the application of the Internet of Things as assistive technology for the diagnosis and treatment of acute asthma exacerbations

Longitudinal changes in the prevalence of adult asthma: An epidemiological survey among Japanese salaried employees and their dependents using healthcare insurance claim from 1999 to 2019

BackgroundInformation on changes in asthma prevalence and the treatment status for asthma is used as basic information for taking medical and administrative measures against asthma. However, this information among adults is relatively limited. MethodsTo elucidate changes in the prevalence of asthma and treatment status over time among Japanese adults, health insurance claim data from some health insurance societies covering salaried employees and their dependents were studied longitudinally. Claim data from FY1999 to 2007 were obtained from two health insurance societies, and data from FY 2011 to 2019 were obtained from three different health insurance societies, and changes in standardized asthma prevalence among subjects aged 20–59 years, proportion of asthma patients prescribed ICS, leukotriene receptor antagonist (LTRA), and LABA, and the mean number of acute asthma exacerbations per year were analyzed. ResultsThe prevalence of asthma increased from 1.6% in 1999 to 3.0% in 2007 and 2.9% in 2011 to 4.6% in 2019. Increased trends in asthma prevalence from 2011 to 2019 were more noticeable in subjects in their 50s than those in their 20s for both sexes. The number of emergency visits related to asthma was 1.5 per year in 1999, which decreased to 0.8 per year in 2019. The proportion of people prescribed all anti-asthma medications (ICS, LTRA, and LABA) increased over time. ConclusionsThe prevalence of adult asthma among Japanese salaried employees and their dependents has increased over the last 20 years, suggesting more attention should be paid to the prevention of this disease in adults.

Rebound in asthma exacerbations following relaxation of COVID-19 restrictions: a longitudinal population-based study (COVIDENCE UK)

BackgroundThe imposition of restrictions on social mixing early in the COVID-19 pandemic was followed by a reduction in asthma exacerbations in multiple settings internationally. Temporal trends in social mixing, incident...

No Specific Factors Associated with Risk of Readmission for Rebound Pain in Children with Sickle Cell Disease and Asthma Treated with Systemic Corticosteroids

Introduction: Asthma occurs in up to 28% of patients with sickle cell disease (SCD) and is associated with increased incidence of vaso-occlusive pain, acute chest syndrome (ACS), and mortality. Systemic steroids are the standard treatment for acute asthma and are often used in patients with SCD, especially as clinical symptoms of acute asthma exacerbations may often overlap with those of ACS. The risk of rebound pain following treatment with corticosteroids has been reported in other studies. However, the temporal association and the factors associated with the risk of rebound vaso-occlusive pain, specifically in those with co-morbid asthma diagnosis, have not been well described. Objective: To evaluate the temporal association between the use of systemic corticosteroids in patients with SCD and asthma and the factors associated with the risk of rebound vaso-occlusive pain. Methods: Patients with confirmed SCD and asthma, between ages 4-18 years of age, and admitted between 2006 and 2009, were eligible. Based on their associations with SCD and asthma, the co-variables of interest evaluated included hydroxyurea (HU) usage, age, sex, atopy, indication for hospitalization, and length of hospital admission. Participants were included if they received systemic glucocorticoids (dexamethasone, methylprednisolone, prednisone, prednisolone) during admission. Participants were excluded if they were receiving chronic blood transfusion therapies or participating in clinical trials involving blood transfusions. Our primary end-point was readmission for rebound vaso-occlusive pain within 14 days of the index admission. Continuous variables were analyzed with the mean (std. deviation) or median (inter-quartile range), based on the distribution, and compared by group with a t test or Somers'd statistic. Categorical variables were analyzed with counts (percent) and compared with a Chi-square statistic. All tests were adjusted for clustering by patients. Results: Fifteen distinct patients, 9 (60%) females, with a total of seventy-six admissions with administration of corticosteroids were included in the analysis (Table). Fifty-seven (75%) of admissions occurred in female patients with a median length of hospitalization of 3.0 days (IQR 2.0 - 4.8). Of the 76 episodes of corticosteroid use, 65 (85.5%) were due to a primary respiratory illness. There were twenty-eight (36.8%) readmissions for rebound vaso-occlusive pain with a median time to readmission of 3.0 (IQR 2.0 - 6.0) days. Amongst all patients, neither sex, history of atopy (>=2 positive skin sensitization tests), indication for hospitalization, or length of hospitalization were associated with the risk of readmission for rebound pain (p=0.425, p=0.540, p=0.721 respectively). Only 2 patients with 5 admissions were documented to be on HU and so we could not assess the relationship to rebound with HU usage. There was a trend for an association of history of early ACS and risk of rebound vaso-occlusive pain. Patients with ACS before the age of 4 were less likely to experience rebound vaso-occlusive pain compared to those without early ACS (P=0.051). Discussion: Our data shows that patients with sickle cell disease and asthma treated with corticosteroids are at risk for readmission due to rebound vaso-occlusive pain in more than one third of episodes (36.8%) following initial corticosteroid exposure. Our study did not identify any specific factors associated with risk of readmission for rebound pain following corticosteroid use. While corticosteroids are life-saving in status asthmaticus, the risk for rebound pain is significant and clinicians should work to optimize chronic asthma therapy to prevent the need for systemic corticosteroids in asthma exacerbations in patients with SCD. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Acute severe asthma in emergency department: clinical characteristics, risk factors, and predictors for poor outcome

BackgroundSevere asthma exacerbation can be a frightening experience to the patient and physician. Despite continuous efforts to frame management guidelines and advances in treatment, severe exacerbations still occur. In order to prevent and judicious management of asthma exacerbations, we should predict them first. This study aims to evaluate distinct clinical trajectories and management outcome of patients with severe asthma exacerbations and also evaluate predictors for poor outcome.MethodsPatients suffering from acute asthma exacerbation and presented to emergency room (forty patients) were grouped into 2 groups (groups A and B) according to severity of exacerbation. Assessment included full clinical history, laboratory investigations (including eosinophil cell count and serum IgE level), Beck’s anxiety and depression inventory scales, assessment of asthma medication adherence and control level, and peak expiratory flow measurement (at presentation, 1 and 6 h after).ResultsFifty-five percent of patients suffered from severe and life-threatening asthma exacerbations, 63.6% of them were females. The most important predictors for severe exacerbations were SO2 < 90% at baseline (OR = 4.56; 95% CI = 3.45–7.56; P < 0.001), PEFR after 1 h (OR= 3.34; 95%CI = 1.90–4.90; P < 0.001), and uncontrolled asthma (OR= 3.33; 95%CI = 2.50–5.05; P < 0.001). Predictors for hospitalization were old age (OR = 1.11; 95%CI = 1.09–2.11; P < 0.001), uncontrolled asthma (OR = 2.34; 95%CI = 2.01–4.40; P < 0.001), PEFR after 1 h (OR= 4.44; 95%CI= 3.24–7.68; P < 0.001), and SO2 <90% at baseline (OR= 5.67; 95%CI= 3.98–8.50; P < 0.001).ConclusionsSevere asthma exacerbations can be predicted by old age, previous history of mechanical ventilation, obstructive sleep apnea, overuse of SABA, uncontrolled asthma, moderate to severe depression, eosinophilia, SO2 <90%, and low peak expiratory flow rates.

Combined synoptic and regional weather patterns affecting atmospheric Poaceae pollen concentrations in Sydney, Australia

Inhalation of grass pollen can result in acute exacerbation of asthma, prompting questions about how grass pollen reaches metropolitan areas. We establish typical atmospheric Poaceae (grass) pollen concentrations recorded at two pollen samplers within the Sydney basin in eastern Australia and analyse their correlation with each other and meteorological variables. We determine the effect of synoptic and regional airflow on Poaceae pollen transport during a period of extreme (≥ 100 grains m−3 air) concentration and characterise the meteorology. Finally, we tested the hypothesis that most Poaceae pollen captured by the pollen samplers originated from local sources. Fifteen months of daily pollen data, three days of hourly atmospheric Poaceae pollen concentrations and fifteen months of hourly meteorology from two locations within the Sydney basin were used. Weather Research Forecasting (WRF), Hybrid Single-Particle Lagrangian Integrated Trajectory (HYSPLIT) modelling and conditional bivariate probability functions (CBPF) were used to assess Poaceae pollen transport. Most Poaceae pollen collected was estimated to be from local sources under low wind speeds. Extreme daily Poaceae pollen concentrations were rare, and there was no strong evidence to support long-distance Poaceae pollen transport into the Sydney basin or across the greater Sydney metropolitan area. Daily average pollen concentrations mask sudden increases in atmospheric Poaceae pollen, which may put a significant and sudden strain on the healthcare system. Mapping of Poaceae pollen sources within Sydney and accurate prediction of pollen concentrations are the first steps to an advanced warning system necessary to pre-empt the healthcare resources needed during pollen season.

Pulse oximetry and peak expiratory flow rate correlations in acute asthma exacerbation in children.

The relationship between oxygen saturation (SpO2) and peak expiratory flow rate (PEFR) in patients with acute asthma is variable. This study aims to assess the predictive value and correlation of this relationship in identifying children with mild symptoms of asthma exacerbation and defining their role in guiding early intervention decision-making. This was a retrospective review of the register of children with asthma seen at the respiratory clinic of a tertiary center in Nigeria from April 2014 to February 2020. Information on their biodata, medical history, clinical status, baseline SPO2, and %predicted PEFR was retrieved and analyzed. The mean values for participants with no symptoms and those with mild symptoms of asthma exacerbation were respectively: SpO2 was 97 ± 1.6% and 96 ± 2.6% (MD: 1.2; 95% CI; 0.7-1.7, P < 0.001); %predicted PEFR: 77.8 ± 17.8 and 64.1 ± 23 (MD; 13.68; 95% CI; 7.3 to 20.0, P < 0.001). Among those with uncontrolled asthma who were having mild symptom exacerbation of their asthma, the correlation between SpO2 and %predicted PEFR was significantly moderate (r = 0.44, P = 0.04). Children with SpO2 between the range of 92%-95% were significantly more likely to have mild symptoms of asthma exacerbation (OR: 2.52,95% CI: 1.22, 5.2, P = 0.01) compared to those with SpO2 >95%. Children with SpO2 of <95% are more likely to have an acute asthma exacerbation. While SpO2 and PEFR have more role in identifying children without acute asthma exacerbation and a limited role in identifying children with mild symptoms of asthma due to their exacerbation due to their moderate to poor correlation.

Spontaneous pneumomediastinum in a young patient with acute asthma exacerbation.

A 16-year-old smoking female, who was diagnosed with allergic asthma at 10 years of age presented to the Emergency Department with new onset dyspnea and non-productive cough unresponsive to treatment with inhaled albuterol This article is protected by copyright. All rights reserved.

Allergic Sensitization Is Crucial for the Suppressive Role of Streptococcus pneumoniae in the Acute Exacerbation of Asthma

Introduction: Allergic sensitization is an important factor in the development, severity, and exacerbation of asthma, which is attributed to type 2 (T2) inflammation. Evidence suggests that respiratory bacterial pathogens (e.g., Streptococcus pneumoniae) exert suppressive effects on airway T2 inflammation. To clarify the role of allergic inflammation in bacterial colonization in asthma based on allergic sensitization, we investigated pharyngeal bacterial colonization, biomarkers (e.g., serum eosinophil cationic protein (ECP) and cytokines/chemokines), and symptoms in the acute exacerbation of childhood asthma. Methods: Pharyngeal samples were collected from 53 children (mean/median age 2.7/2.5 years). Serum levels of total and allergen-specific IgE against aeroallergens, ECP, and 17 cytokines/chemokines were measured. Results: Allergic sensitization was recognized in 62.2% patients. S. pneumoniae, Moraxella catarrhalis, Haemophilus influenzae, and other bacteria were detected in 47.1%, 11.3%, 11.3%, and 30.1% of all patients, respectively. Patients with S. pneumoniae had a significantly shorter duration of wheezing than those without (4.7 ± 3.6 vs. 7.1 ± 3.5 days, p = 0.024). In patients with allergic sensitization, patients with S. pneumoniae had a significantly shorter duration of wheezing than those without (4.0 ± 3.6 vs. 7.7 ± 4.0 days, p = 0.003). Serum total IgE was significantly lower in patients with S. pneumoniae than in those without (81.9 [7.8–894] vs. 287 [4.4–1,840] IU/mL, p = 0.014). Serum ECP was significantly higher (33.1 [2–109] vs. 7.8 [3–35] ng/mL, p = 0.042), and IFN-γ was significantly lower (5.6 [4–10] vs. 16.4 [7–28] pg/mL, p = 0.032) in patients with allergic sensitization than those without. Discussion/Conclusion: Our results suggested that the suppressive effects of S. pneumoniae colonization were observed only in patients with allergic sensitization, wherein serum total IgE, ECP, and IFN-γ may have an important role on acute exacerbation of asthma.

The Clinical Respiratory Score: investigating the reliability of an asthma scoring tool across a multidisciplinary team

Background Asthma scoring tools are used by emergency department (ED) teams to communicate severity of illness. Although most have been validated, none has been found to be sufficiently valid to allow for use across a multidisciplinary team managing pediatric asthma exacerbations. Objective We sought to evaluate the inter-rater reliability of the Clinical Respiratory Score (CRS) among all members of an ED care team. Design/Methods We conducted a retrospective study of children aged 2 to 18 years presenting with an acute asthma exacerbation to an urban pediatric ED over a 2-year period. We determined reliability using two CRS measurements independently documented by two separate providers, 15 min apart. An inter-class correlation coefficient (ICC) was calculated to determine overall reliability among users. Subgroup analysis was conducted to determine reliability between types of providers and the six components of the CRS. Results A total of 9,749 patient encounters were identified and 1,562 (16%) met our inclusion criteria. The majority of score pairings (n = 1096, 70.2%) were documented by a registered nurse followed by a respiratory therapist. The overall reliability of the CRS, when documented by two providers, was acceptable with an ICC of 0.76 (95% CI: 0.74-0.78, p < 0.001). Removing CRS components with the lowest agreement did not affect the overall ICC when re-calculated. Conclusion(s) The CRS is a reliable asthma severity scoring tool for pediatric patients presenting with an acute asthma exacerbation when utilized across care team members. Simplifying the CRS by removing the color and mental status components did not affect its reliability.