Clinical Asthma Score Research Articles

The evaluation of clinical asthma score for outpatient management of childhood asthma in Siriraj hospital

The evaluation of clinical asthma score for outpatient management of childhood asthma in Siriraj hospital

IV Theophylline Still Works in Severe Status Asthmaticus

Critical Care| August 01 2001 IV Theophylline Still Works in Severe Status Asthmaticus AAP Grand Rounds (2001) 6 (2): 13–14. https://doi.org/10.1542/gr.6-2-13 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation IV Theophylline Still Works in Severe Status Asthmaticus. AAP Grand Rounds August 2001; 6 (2): 13–14. https://doi.org/10.1542/gr.6-2-13 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: status asthmaticus, theophylline Source: Ream RS, Loftis LL, Albers GM, et al. Efficacy of IV theophylline in children with severe status asthmaticus. Chest. 2001;119:1480–1488. Forty-seven children (median age, 8.3 years; range, 13 months to 17 years) were enrolled in a randomized controlled study at Cardinal Glennon Pediatric Research Institute, Saint Louis University, to examine the role of theophylline in severe asthma. All children were treated with methylprednisolone, continuous nebulized albuterol and intermittent nebulized ipratropium bromide. Intravenous terbutaline sulfate was added to the “standard care” regimen when the patients had increased levels of respiratory distress or a rising PaCO2. Children were randomized to receive additional theophylline or “standard” care alone. Target theophylline levels were 12–17 mcg/ml. The Wood Downes1 Clinical Asthma Score was used to assess asthma severity and was assigned by a physician blinded to the treatment assignment. Twenty-three children received theophylline and 24 received “standard” therapy without theophylline. The treatment and control groups had similar ages, Clinical Asthma Scores, blood gases values, baseline use of anti-inflammatory therapy and intensity of acute asthma care in the emergency department. Three children in each group received mechanical ventilation that was initiated prior to institution of theophylline. Among children who did not require mechanical ventilation, those treated with theophylline had more rapid improvement in Clinical Asthma Scores compared to the control group. The average time to a clinical asthma score of < 3 was 19 hours for the theophylline group compared to 31 hours in the control group (P<.05). However, the average length of stay in the ICU did not differ between treatment groups for children who did not receive mechanical ventilation. Among children who received mechanical ventilation, both the time to a Clinical Asthma Score < 3 (66 hours vs 191 hours) and the time to discharge criteria from the ICU (3.9 days vs 8.8 days) were significantly shorter for the children treated with theophylline. The average doses of continuous nebulized albuterol and intravenous terbutaline did not differ between the treatment groups. Children who received theophylline experienced significantly more vomiting. The authors suggest that combined therapy that includes theophylline for children with severe asthma exacerbations may reduce the incidence of respiratory failure and decrease hospital length of stay. In the recent past, theophylline was a mainstay of acute, severe asthma therapy. For acute bronchodilation, it has largely been replaced by aggressive administration of ß-agonists that have a much broader therapeutic index. Theophylline continues to be recommended as chronic therapy for children with persistent wheezing despite use of inhaled steroids and ß-agonists and for children with nocturnal wheezing.2 Toxicity is common and includes nausea, headache, insomnia, seizure, encephalopathy, electrolyte abnormalities and cardiac arrhythmias. Simultaneous administration of other drugs such as cimetidine and erythromycin interfere with drug clearance and may lead to toxic levels. This study is the second report demonstrating a benefit when theophylline was added to “standard” therapy (systemic corticosteroids, inhaled and intravenous ß-agonists and inhaled anticholinergics) for severe asthma exacerbations. The first... You do not currently have access to this content.

Efficacy of IV The ophylline in Children With Severe Status Asthmaticus

To determine whether adding IV theophylline to an aggressive regimen of inhaled and IV beta-agonists, inhaled ipratropium, and IV methylprednisolone would enhance the recovery of children with severe status asthmaticus admitted to the pediatric ICU (PICU). A prospective, randomized, controlled trial. Asthma scoring was performed by investigators not involved in treatment decisions and blinded to group assignment. The PICU of an urban, university-affiliated, tertiary-care children's hospital. Children with a diagnosis of status asthmaticus who were admitted to the PICU for < or = 2 h and who were in severe distress, as indicated by a modified Wood-Downes clinical asthma score (CAS) of > or = 5. All subjects initially received continuous albuterol nebulizations; intermittent, inhaled ipratropium; and IV methylprednisolone. The theophylline group was also administered infusions of IV theophylline to achieve serum concentrations of 12 to 17 microg/mL. A CAS was tabulated twice daily. Forty-seven children (median age, 8.3 years; range, 13 months to 17 years) completed the study. Twenty-three children received theophylline. The baseline CASs of both groups were similar and included three subjects receiving mechanical ventilation in each group. All subjects receiving mechanical ventilation and theophylline were intubated before drug infusion. Among the 41 subjects who were not receiving mechanical ventilation, those receiving theophylline achieved a CAS of < or = 3 sooner than control subjects (18.6 +/- 2.7 h vs 31.1 +/- 4.5 h; p < 0.05). Theophylline had no effect on the length of PICU stay or the total incidence of side effects. Subjects receiving theophylline had more emesis (p < 0.05), and control patients had more tremor (p < 0.05). Theophylline safely hastened the recovery of children in severe status asthmaticus who were also receiving albuterol, ipratropium, and methylprednisolone. The role of theophylline in the management of asthmatic children in impending respiratory failure should be reexamined.

Emergency Department Use of Ketamine in Pediatric Status Asthmaticus*

The objective of this study was to evaluate the effects of adding ketamine to standard emergency department (ED) therapy for patients with status asthmaticus. This was a prospective observational study. Ten patients with an acute exacerbation of asthma who were unresponsive to standard therapy were enrolled in the ED. Upon enrollment, children received ketamine at a loading dose of 1 mg/kg intravenously (i.v.), followed by a continuous infusion of 0.75 mg/kg/hr (12.5 μg/kg/min) for 1 hr. Clinical asthma score (CAS), vital signs, and peak expiratory flow (PEF) measurements were obtained prior to ketamine administration, within 10 min after ketamine administration was completed, and 1 hr after infusion. Median CAS on ED arrival was 15 (range 7–23) and did not significantly change immediately prior to infusion of ketamine (median 14, range 8–21). Median CAS decreased to 10.5 immediately after infusion and to 9.51 hr post ketamine infusion (37% reduction, p < 0.05 by ANOVA vs. preketamine CAS). Median respiratory rate (RR) also decreased from 39 prior to ketamine to 30 immediately following ketamine administration (25% decrease vs. preketamine; p < 0.05). Oxygen saturation significantly improved after ketamine infusion, although 5 patients remained on oxygen. Median PEF improved after infusion, but was not statistically significant. Four patients experienced mild side effects including mild hallucinations, diffuse flushing, and moderate hypertension. Side effects resolved with benzodiazepines or with discontinuation of the infusion. Addition of ketamine to standard therapy was associated with improved indices of acute asthma severity. Side effects were transitory and comparable to previous studies. However, a double-blinded randomized controlled trial needs to be conducted to determine if improvement is attributable to the addition of ketamine to standard asthma therapy.

Promises and pitfalls in the evaluation of pediatric asthma scores

Promises and pitfalls in the evaluation of pediatric asthma scores

Asthma from childhood to adulthood: course and outcome of lung function

Lung function (FEV1before and after bronchodilatation) was studied prospectively over five visits in 55 asthmatic children (28 boys) from childhood to adulthood (age 30). At the last follow-up recordings were made at rest, after cold air challenge (CACh), and after bronchodilatation. Results were related to clinical asthma scoring and to sensitization to furred animals, as described in a companion paper.Lung function outcome was shown to be influenced by initial FEV1(% predicted) and gender, but not by initial asthma severity or sensitization. FEV1(% predicted) was higher in females than in males over the first two follow-ups, but the reverse was found over the subsequent visits. It deteriorated from childhood to adulthood in the females but improved in the males. In adulthood the females (for height 170 cm) had a steeper normalized annual fall in post-bronchodilator FEV1than the males (55±38 vs. 25±36 ml;P=0·006). The degree of bronchial hyper-responsiveness was associated significantly with asthma severity and the extent of sensitization to furred animals, but not with gender.The results indicate a better lung function outcome for asthmatic boys than for girls, confirming trends seen in clinical asthma severity. In adulthood the extent of sensitization to relevant perennial inhaled allergens significantly influences airway responsiveness and asthma severity, but not lung function.

A single dose of intramuscularly administered dexamethasone acetate is as effective as oral prednisone to treat asthma exacerbations in young children

Objective: To evaluate whether a single dose of intramuscularly administered dexamethasone acetate (IM Dex) was as safe and effective as a 5-day course of oral prednisone (PO Pred) in the treatment of young children with mild-moderate exacerbations of asthma. Study design: A prospective, randomized, investigator-blinded study was done in a tertiary care medical center in children (6 months to 7 years of age) who required corticosteroids to treat mild-moderate asthma exacerbations as outpatients. Patients were randomized to receive either a single dose of IM Dex (~1.7 mg/kg) or PO Pred (~2 mg/kg/d for 5 days). Clinical asthma score, behavioral changes, albuterol use, and tolerance of the medication were recorded in a home diary for 7 days. Cortisol/creatinine ratios on first morning void urine samples were obtained on day 14. The primary outcome measures were changes in clinical asthma score through day 5 and tolerance of the medication. Results: Fifteen patients in the IM Dex group (mean age 37 months) and 17 in the PO Pred group (mean age 36 months) completed the study. Clinical asthma score improved significantly in both groups during the first 5 days of therapy, and no significant difference was seen in the rate of improvement between the 2 groups. Three children refused more than 75% of their prednisone doses, and another 4 missed 30% to 50% of the doses despite their parents’ best efforts. The intramuscular injection caused no complications, and approximately 70% of parents in both groups stated that they would choose IM Dex to treat their child’s next asthma exacerbation. Conclusion: In this group of children a single intramuscular injection of dexamethasone acetate was as effective as a 5-day course of PO Pred for the management of mild-moderate outpatient asthma exacerbations. (J Pediatr 2000;136:298-303)

Oral versus intravenous corticosteroids in children hospitalized with asthma

Background: Previous studies have demonstrated that in the emergency treatment of an asthma exacerbation, corticosteroids used in conjunction with β-agonists result in lower hospitalization rates for children and adults. Furthermore, orally administered corticosteroids have been found to be effective in the treatment of outpatients with asthma. However, similar data in inpatients is lacking. Objective: The purpose of this study was to determine the efficacy of oral prednisone versus intravenous methylprednisolone in equivalent doses for the treatment of an acute asthma exacerbation in hospitalized children. Methods: We conducted a randomized, double-blind, double-placebo study comparing oral prednisone at 2 mg/kg/dose (maximum 120 mg/dose) twice daily versus intravenous methylprednisolone at 1 mg/kg/dose (maximum 60 mg/dose) four times daily in a group of patients 2 through 18 years of age hospitalized for an acute asthma exacerbation. All patients were assessed by a clinical asthma score 3 times a day. The main study outcome was length of hospitalization; total length of stay and time elapsed before β-agonists could be administered at 6-hour intervals. Duration of supplemental oxygen administration and peak flow measurements were secondary outcome measures. Results: Sixty-six patients were evaluated. Children in the prednisone group had a mean length of stay of 70 hours compared with 78 hours for the methylprednisolone group ( P = .52). Children in the prednisone group were successfully weaned to β-agonists in 6-hour intervals after 59 hours compared with 68 hours for the methylprednisolone group ( P = .47). Patients receiving prednisone required supplemental oxygen for 30 hours compared with 52 hours for the methylprednisolone group ( P = .04). Conclusion: There was no difference in length of hospital stay between asthmatic patients receiving oral prednisone and those receiving intravenous methylprednisolone. Because hospitalization charges are approximately 10 times greater for intravenous methylprednisolone compared with oral prednisone, the use of oral prednisone to treat inpatients with acute asthma would result in substantial savings. (J Allergy Clin Immunol 1999;103:586-90.)

Prednisolone in acute childhood asthma: clinical responses to three dosages

Ninety-eight children aged 1–15 years entered a randomized double-blind study investigating an appropriate dose of oral prednisolone in children admitted to hospital with an acute exacerbation of asthma. None of the children had recently been treated with oral prednisolone. Following admission, the children were randomized to receive prednisolone 0·5 mg kg −1, 1·0 mg kg −1 or 2·0 mg kg −1 in a single daily dose in addition to nebulized bronchodilators. Clinical asthma scores, oxygen saturations, pulse rate, duration of admission and number of nebulizers given were compared in the three treatment groups. Thirty-five children received 0·5 mg kg −1, 33 received 1·0 mg kg −1 and 30 received 2·0 mg kg −1. There were no significant differences in the pattern of recovery between the three treatment groups. There were no advantages in using higher doses of prednisolone. We recommend 0·5 mg kg −1 day −1 of prednisolone as an appropriate dose for treating an acute exacerbation of asthma.

Development of a clinical asthma score for use in hospitalized children between 1 and 5 years of age

The objective of this study was to develop a clinical asthma score (CAS) for use in hospitalized children between 1 and 5 years of age. Formal approaches to item selection and reduction, reliability, discriminatory power, validity, and responsiveness were used. The final CAS consisted of five clinical characteristics: respiratory rate, wheezing, indrawing, observed dyspnea, and respiratory-to-expiratory ratio. Interrater reliability was high (weighted kappa = 0.82), and the CAS was discriminatory (Ferguson's δ = 0.92). The CAS was valid, with a strong correlation with length of hospital stay (Spearman's correlation = 0.47, p < 0.05) and drug dosing interval (Spearman's correlation = -0.58, p < 0.01). The CAS was responsive, with a significant change in CAS from admission to discharge (Wilcoxon signed rank test, p < 0.01). This score, for use in hospitalized preschool children, is reliable, discriminatory, valid, and responsive.

Clinical scores for acute asthma in pre-school children. A review of the literature

The objective of this paper was to evaluate the applicability in research and clinical practice of clinical scores for acute asthma in pre-school children. All instruments were reviewed according to a standardized set of criteria: purpose of the score, suitability for use in children, inter-observer agreement, validity and responsiveness. A Medline literature research resulted in 16 different clinical asthma scores, which have been developed to assess the severity of acute asthma, to predict the outcome of an attack, or to evaluate the response to treatment. Most asthma scores could be easily obtained in children. Three scores have been modified to facilitate application in a younger age-category. Inter-observer agreement has received little attention, although all scores contained items that require subjective judgement. The predictive validity was insufficient to justify the application of clinical scores as a decision rule for the admission or discharge of children with acute asthma. Asthma scores seem to be useful for assessing the severity of an attack and evaluating the response to therapy, but as yet there is insufficient information on the performance of the scores to justify a preference. Wheezing and retractions appear to be important items of any useful score for acute asthma.

Low-Dose β-Agonist Continuous Nebulization Therapy for Status Asthmaticus in Children

The role of continuous nebulization therapy (CNT) with low-dose beta (beta) agonist was retrospectively reviewed in 7 children admitted to a pediatric intensive care unit for treatment of acute severe asthma. Clinical asthma score (CAS), alveolar-arterial oxygen difference (A-aDO2), PaCO2, heart rate, and respiratory rate were recorded at 0, 12, and 24 hr of CNT. All patients had a decrease in CAS at 12 hr (p < 0.008) and decreased A-aDO2, PaCO2, respiratory rate, and heart rate at 24 hr (p < 0.008). No patient required escalation of dosage or additional intervention such as intravenous beta-agonist therapy or mechanical ventilation. No patient experienced significant cardiovascular toxicity or hypokalemia. We conclude that CNT with low-dose beta agonists should be considered in the initial approach to therapy in children with acute severe asthma.

Continuous nebulised salbutamol and oral once a day prednisolone in status asthmaticus.

A trial was conducted of continuous nebulised salbutamol and oral once a day prednisolone in a group of 11 children with status asthmaticus (group A) and compared with a conventional protocol comprising aminophylline infusion and intravenous hydrocortisone every six hours in a matched control group (group B). Monitoring by a clinical asthma score, pulse oximetry (oxygen saturation, SaO2), and peak expiratory flow rate (PEFR) revealed earlier improvement in these parameters in group A. Significant differences in mean SaO2 values appeared after 12 and 18 hours respectively. Mean PEFR percentage values were higher in group A compared with group B. A larger number (9/11) of patients could be discharged from hospital within 24 hours in group A compared with group B where only 3/11 could be discharged. All patients recovered without any side effects. It is concluded that continuous nebulised salbutamol and oral once a day prednisolone is safe and effective in treatment of children with status asthmaticus.

Hospital treatment of asthma: lack of benefit from theophylline given in addition to nebulized albuterol and intravenously administered corticosteroid

To determine the efficacy of theophylline when given in addition to nebulized albuterol and intravenously administered corticosteroid to children hospitalized with mild to moderate asthma. Randomized, prospective, placebo-controlled, double-blind trial. Tertiary-care children's hospital. Twenty-nine patients with asthma between the ages of 2 and 16 years completed the study. The treatment and placebo groups were similar in age, gender, race, illness severity, and emergency department treatment. All patients received intravenously administered methylprednisolone and nebulized albuterol. The treatment group received intravenous theophylline therapy and the placebo group dextrose in water. When intravenously administered medications were discontinued, therapy continued with oral administration of theophylline (or placebo) and of prednisone. Twice-daily assessments of clinical asthma symptoms were made by using a scoring system consisting of respiratory rate, inspiratory/expiratory ratio, wheeze, and accessory muscle use. Time required to reach study discharge criteria (asthma score < or = 2) (30.4 +/- 16.8 vs 27.0 +/- 10.3 hours; p = 0.51) and the rate of improvement of the clinical asthma score (-0.10 +/- 0.05 unit/hr vs -0.11 +/- 0.09 unit/hr; p = 0.88) were not significantly different between the theophylline and placebo groups. The number of albuterol aerosol treatments required and the adverse effects experienced were not significantly different between groups. When the combination of systemically administered corticosteroid and inhaled albuterol is used in the treatment of children hospitalized with mild to moderate asthma, addition of theophylline may not be justified.

Pitfalls in the use of clinical asthma scoring: Baker MD. AJDC 1988; 142:183–185

Pitfalls in the use of clinical asthma scoring: Baker MD. AJDC 1988; 142:183–185

Improvement in clinical asthma score and Paco 2 in children with severe asthma treated with continuously nebulized terbutaline

We analyzed continuous nebulized terbutaline (CNT) therapy in 19 patients with 27 admissions for severe asthma and impending respiratory failure who failed to respond to our standard asthma protocol of methylprednisolone, aminophylline, and intermittently nebulized terbutaline. Terbutaline was administered by continuous face mask nebulization at a dose equaling the most frequent previous intermittent dose per hour (4 mg per hour). No patient with frank respiratory failure (i.e., Paco 2 ⩾60 torr, exhaustion, or coma) was studied. All patients improved, and therapy was stopped in a mean of 15.4 hours (range 3 to 37 hours). The average heart rate did not increase over baseline measurements through 24 hours of CNT. The mean clinical asthma score improved significantly during 8 hours, falling from 6.9 to 3.2 ( p > 0.001). In 14 patients whose Paco 2 was ⩾39 torr (range 39 to 58 torr) and clinical asthma score was 6 or greater, Paco 2 decreased a mean of 11.7 torr during a mean of 8.1 hours. In six patients whose Paco 2 was 45 torr or greater at the start of CNT (mean 49, range 45 to 58 torr) and in whom we would have previously treated with intravenous isoproterenol, Paco 2 decreased a mean of 15 torr in an average of 8.7 hours. This preliminary study suggests that CNT is an effective therapy for severe asthma in children.

Pitfalls in the use of clinical asthma scoring.

We evaluated the correlation of the Wood-Downes-Lecks clinical asthma score (CAS) with outcome in 210 consecutive known asthmatic children presenting to an urban emergency department for treatment of acute asthma. All children received standard treatment consisting of administration of beta-adrenergic agents and theophylline compounds. Clinical asthma scores were assigned before each treatment phase and before disposition from the emergency department. Ten-day follow-up information was collected on each patient by telephone. While no differences in pretreatment CASs were found between outcome groups, disposition CASs were found to be significantly higher in patients eventually admitted to the hospital as opposed to those discharged home. However, CASs were not effective in identifying either those patients who required prolonged hospitalization (greater than 24 hours) or those who sustained ongoing disability following discharge home from the emergency department. These data indicate that the CAS alone is not a reliable indicator of severity of acute asthma of childhood as judged by subsequent disability.