Clinical Asthma Score Research Articles

Nasal Continuous Positive Airway Pressure With Heliox Versus Air Oxygen in Infants With Acute Bronchiolitis: A Crossover Study

The purpose of this work was to evaluate the effects of administering either heliox or air oxygen in combination with nasal continuous positive airway pressure in infants with refractory bronchiolitis. We conducted a prospective, interventional, single-center, crossover study in a teaching hospital including infants 1 month to 2 years of age, consecutively admitted to the PICU from February 2004 to February 2005 for treatment of severe acute bronchiolitis unresponsive to therapy. Patients with a clinical score (Modified Wood's Clinical Asthma Score) of >5, arterial oxygen saturation of <92%, or transcutaneous CO(2) pressure of >50 mmHg despite supportive therapy, nebulized L-epinephrine, and heliox therapy through a nonrebreathing reservoir face mask were eligible. During the study period, 40 infants with bronchiolitis were admitted to the PICU; 12 fulfilled inclusion criteria. A predetermined balanced sequential allocation to either 30 minutes of treatment with nasal continuous positive airway pressure with heliox or to air-oxygen nasal continuous positive airway pressure was performed. Measurements were taken at baseline and after 30 minutes of each treatment. Baseline mean values were as follows: nasal continuous positive airway pressure of 7.2 cmH(2)O; clinical score of 7.7 points; transcutaneous CO(2) pressure of 61.6 mmHg; and arterial oxygen saturation of 88.6%, with the fraction of inspired oxygen at 35.4%. Clinical score, transcutaneous CO(2) pressure, and arterial oxygen saturation improved during the study time with both heliox-nasal continuous positive airway pressure and air-oxygen-nasal continuous positive airway pressure: after 1 hour, the clinical score fell 1.7 points, transcutaneous CO(2) pressure decreased 8.2 mmHg, and arterial oxygen saturation increased by 7.7%. Improvement in clinical score was double with heliox-nasal continuous positive airway pressure compared with the air-oxygen-nasal continuous positive airway pressure (2.12 vs 1.08 points), and the fall in the transcutaneous CO(2) pressure was greater with heliox-nasal continuous positive airway pressure compared with air-oxygen-nasal continuous positive airway pressure (9.7 vs 5.4 mm Hg). There was no difference in arterial oxygen saturation between groups. No patients required endotracheal intubation. No adverse effects attributable to either of the study interventions were detected. Nasal continuous positive airway pressure improves the clinical score and the CO(2) elimination of infants with refractory bronchiolitis. These positive effects are significantly enhanced when nasal continuous positive airway pressure is combined with heliox instead of air oxygen. Both techniques are noninvasive, seem safe, and may reduce the need for endotracheal intubation.

The pediatric respiratory assessment measure (PRAM)

The PRAM has been a validated clinical asthma score for assessing asthma severity in preschool and school-aged children since its report as the Preschool Respiratory Assessment Measure in The Journal in 2000. In this issue of The Journal, Ducharme et al from Montreal Children’s Hospital report on a prospective cohort study that expands the age range from 3-6 years to 2-17 years. The authors acknowledge that one limitation of this study (which used admission rates as an outcome) is that the admitting physician was not blinded to the PRAM values which could have influenced the decision to admit. Overall, however, the PRAM appears to be a useful tool to evaluate asthma severity in children age 2-17 years. We would hope to see further studies validating its use, particularly in patients with greater severity.

Intramuscular Dexamethasone is Equivalent to Oral Prednisolone for Asthma Exacerbations

Emergency Care| January 01 2008 Intramuscular Dexamethasone is Equivalent to Oral Prednisolone for Asthma Exacerbations AAP Grand Rounds (2008) 19 (1): 1–2. https://doi.org/10.1542/gr.19-1-1 Connected Content This is a related article to: Weighing the Evidence: PICO Questions: What Are They, and Why Bother? 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 Intramuscular Dexamethasone is Equivalent to Oral Prednisolone for Asthma Exacerbations. AAP Grand Rounds January 2008; 19 (1): 1–2. https://doi.org/10.1542/gr.19-1-1 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: asthma, acute, dexamethasone, intramuscular injections, prednisolone, asthma, single-dose regimen Source: Gordon S, Tompkins T, Dayan P. Randomized trial of single-dose intramuscular dexamethasone compared with prednisolone for children with acute asthma. Pediatr Emerg Care. 2007;23(8):521–527; doi:10.1097/PEC.0b013e318128f821 Steroids are recommended for moderate to severe asthma exacerbations by the National Asthma Education and Prevention Program.1 Emesis of oral prednisolone syrup is not uncommon and may result in hospitalization, a need for intravenous steroids, or suboptimal therapy.2,–4 Researchers from Columbia University compared the clinical efficacy of a single dose of intramuscular dexamethasone sodium phosphate (IM dex) to a five-day course of oral prednisolone for the treatment of children with asthma exacerbations. Patients aged 18 months to six years were enrolled if they presented with a mild to moderate asthma exacerbation and had a history of at least two prior episodes of respiratory illnesses treated with bronchodilators. Prior to initial treatment, the severity of symptoms in study children was assessed by a clinical asthma score based on respiratory rate, retractions, and wheezing (score range of 0–9). Patients who had scores between 3 and 7 were randomized to receive either IM dex (0.6 mg/kg, maximum 15 mg) or oral prednisolone suspension (2 mg/kg, maximum 50 mg). Patients who had emesis of prednisolone within 30 minutes of administration were redosed. Patients who had emesis after the second dose of prednisolone were given intravenous (IV) methylprednisolone (2 mg/kg). Patients receiving IM dex received no further steroid therapy; those randomized to receive oral prednisolone were prescribed an additional four doses to be given daily. Data on study children who required admission to the hospital were not included in the final analysis. A repeat clinical asthma score was obtained in study children 96 to 120 hours after enrollment. The primary study outcome was change in the clinical asthma score between enrollment and the four-day follow-up evaluation in children discharged from the emergency department. Data for secondary outcomes were obtained through structured interviews with the parents of study patients at four and 14 days after enrollment. There were 88 patients randomized to the IM dex group and 93 to the oral prednisolone group. The demographics of the two groups were similar. Initial mean clinical asthma scores were 4.6 in IM dex patients and 4.4 in prednisolone patients. Admission rates were similar with 17/88 (19%) IM dex patients requiring admission compared to 19/93 (20%) oral prednisolone patients. Emesis occurred in six (6%) prednisolone patients; three of these children had a second episode of emesis and were given IV methylprednisolone. Guardians of patients in the prednisolone group reported 94% compliance with administration of at least three doses. At the four-day follow-up assessment, there was no difference in the change in mean clinical asthma score between the IM dex group and oral prednisolone group. There were also no clinically meaningful differences in secondary outcome measures including respiratory signs at four-day follow-up, admission rates within 14 days, or unplanned physician visits within 14 days. Emesis occurred at least one time in 9/69 (13%) of... You do not currently have access to this content.

Childhood Overweight Increases Hospital Admission Rates for Asthma

Although childhood overweight has been associated with increased hospital lengths of stay for patients with asthma, the possible relationship between overweight and hospital admission for asthma has not been well studied. We hypothesized that overweight children who presented to the emergency department with asthma exacerbations were more likely to be admitted to the hospital than nonoverweight children. A retrospective chart review was conducted of all children who were older than 2 years and presented to the emergency department with an asthma exacerbation in calendar year 2005. Children with chronic medical conditions other than asthma were excluded. Children were classified as nonoverweight (< or = 95% weight-for-age percentile) or overweight (> 95% weight for age). During the study period, there were 884 visits to the emergency department for an asthma exacerbation by 813 children; 238 (27%) were admitted to the hospital, and 33 (4%) were admitted to the ICU. Overall, hospital admission was associated with higher clinical asthma score but not with age, gender, or poverty status (as quantified as home in zip-code areas designated as "impoverished"). Overweight children (n = 202 [23%]) were significantly older (8.5 +/- 4.4 vs 7.3 +/- 4.3 years) and more likely to live in an impoverished area (37% vs 28%). Presenting clinical asthma score and therapeutic interventions in the emergency department were similar for overweight and nonoverweight children; however, overweight children were significantly more likely to be admitted to the hospital. Overweight children who present to the emergency department with acute asthma exacerbations are significantly more likely to be admitted to the hospital than nonoverweight children. This identifies an important area in which childhood overweight has a significant impact on the health of children with asthma.

Randomized Trial of Single-Dose Intramuscular Dexamethasone Compared With Prednisolone for Children With Acute Asthma

To compare the clinical efficacy of single-dose intramuscular (IM) dexamethasone phosphate to a 5-day course of oral prednisolone for the treatment of moderate asthma exacerbations in young children discharged from the emergency department (ED). We performed a prospective, randomized trial in children aged 18 months to less than 7 years with asthma who presented to the ED with a clinical asthma score of 3 to 7 on a 9-point scale. Children were randomized to 1 dose of IM dexamethasone (0.6 mg/kg, maximum 15 mg) or oral prednisolone (2 mg/kg, maximum 50 mg) once daily for 5 days. The primary outcome, measured only for patients discharged from the ED, was change in asthma score from ED presentation to 4-day follow-up examination, as assessed by a physician masked to group assignment. We assessed secondary clinical course outcomes by a structured interview at 4 and 14 days. Eighty-eight patients were appropriately randomized to dexamethasone and 93 to prednisolone. Group characteristics were similar at baseline. Among those discharged from the ED, 62 (90%) of 69 and 64 (90%) of 74 patients in the dexamethasone and prednisolone groups, respectively, were reassessed at 4 days for the primary outcome. The mean change in total asthma score at 4-day follow-up was 3.6 in the dexamethasone group and 3.4 in the prednisolone group (difference, 0.2; 95% confidence interval, -0.4 to 0.7). Of patients initially discharged, 5.9% of dexamethasone patients and 4.1% of prednisolone patients were admitted before the 2-week follow-up (difference, 1.8%; 95% confidence interval, -5.4% to 9.0%). A single dose of IM dexamethasone showed no clinically meaningful difference in outcomes compared with a 5-day course of oral prednisolone for the treatment of moderate acute asthma exacerbations in young children who are discharged from the ED.

Randomized controlled trial of ipratropium bromide and salbutamol versus salbutamol alone in children with acute exacerbation of asthma

To evaluate effect of addition of ipratropium to salbutamol delivered by metered dose inhaler and spacer in the beginning of treatment of mild to moderate exacerbation of asthma. Children between 5 to 15 years of age with mild to moderate exacerbation of asthma were randomized to receive either a combination of ipratropium bromide and salbutamol or salbutamol alone administered by metered dose inhaler and spacer. The effects on clinical asthma score and spirometric parameters were compared. A total of 60 children were randomized in the study. The baseline characteristics of two groups were comparable. Children getting combination of salbutamol and ipratropium showed significantly greater improvement in percent-predicted PEFR and FEF25-75% than children receiving salbutamol alone. There was beneficial effect of addition of ipratropium to salbutamol administered by MDI with spacer at the beginning of therapy for mild to moderate acute exacerbation of asthma in children.

Effectiveness of nebulized furosemide added to nebulized salbutamol in children with acute asthma

Background Nebulized furosemide has been shown to be protective against bronchoconstricting stimuli. Methods To investigate whether inhaled furosemide would exhibit an additional therapeutic effect in children with acute asthma we performed a double-blind, placebo-controlled study in which patients with acute asthma attack were randomized to receive either nebulized salbutamol (0.15 mg/kg) plus nebulized furosemide (10 mg/m2) or nebulized salbutamol (0.15 mg/kg) plus nebulized saline as placebo. In all patients, clinical asthma scores (CAS) were determined before and after drug administration. Peak expiratory flow rates (PEFR) were measured by a peak flow meter. Results CAS and PEFR improved in both groups with nebulized salbutamol treatment. The CAS changed from 3.56 ± 2.13 to 2.06 ± 1.84 (p = 0.0001) in the study group and from 4.44 ± 2.63 to 2.56 ± 1.86 (p = 0.0003) in the control group. PEFR increased from 177.50 ± 65.88 to 221.88 ± 66.05 L/min in the first group (p = 0.0001) and from 183.13 ± 51.73 to 218.13 ± 60.25 in the second group (p = 0.0001). Conclusion Adding nebulized furosemide to nebulized salbutamol in pediatric patients experiencing an acute asthma attack did not produce greater improvement in clinical (p = 0.3829) or spirometric (p = 0.3839) parameters than nebulized salbutamol alone.

Protocol‐based titration of intravenous terbutaline decreases length of stay in pediatric status asthmaticus

Although frequently used to treat status asthmaticus in children, intravenous (IV) terbutaline has not been shown to decrease hospital length of stay (LOS). We theorized that this lack of demonstrable benefit resulted from variations in dosing and titration, rather than the drug per se, and that intensive care unit (ICU) LOS would be shortened by the administration of terbutaline according to a protocol incorporating a quantitative assessment of severity of illness. We prospectively treated 20 consecutive children with status asthmaticus with IV terbutaline according to a protocol that titrated the dose based on a clinical asthma score, the Modified Pulmonary Index Score (MPIS). Data were compared to a historic cohort of the previous 20 consecutive ICU patients with status asthmaticus who were treated with IV terbutaline prior to initiation of the protocol. Patients who received terbutaline by standardized protocol had significantly shorter ICU LOS (3.5 +/- 1.1 vs. 5.0 +/- 2.0 days, P = 0.01), shorter hospital LOS (5.5 +/- 1.3 vs. 8.3 +/- 2.7 days, P < 0.01), and reduced hospital charges ($19,298 +/- $10,516 vs. $26,528 +/- $12,328, P = 0.04). The method of administration of IV terbutaline significantly influenced ICU length of stay and hospital charges.

Efficacy Similar for Levalbuterol, Racemic Albuterol in Acute Asthma

Source: Qureshi F, Zaritsky A, Welch C, et al. Clinical efficacy of racemic albuterol versus levalbuterol for the treatment of acute pediatric asthma. Ann Emerg Med. 2005;46:29–36. Albuterol is the mainstay of therapy for patients with acute asthma. The drug typically comes in a racemic form, with equal parts of the R- and S-enantiomer. Levalbuterol, marketed as Xopenex (Sepracor Inc., Marlborough, Mass.), consists of only the R-isomer. It has been suggested that the R-enantiomer of albuterol is responsible for the drug’s bronchodilating effects1 and that the S-enantiomer is responsible for adverse effects, including tachycardia, tremors, and nervousness.2 While some studies have concluded that levalbuterol is more effective than racemic albuterol with fewer side effects, the data are inconclusive.3,4 Researchers from the Children’s Hospital of the King’s Daughters, Eastern Virginia Medical School in Norfolk, Va., conducted a prospective, double-blind, randomized, controlled efficacy study to compare levalbuterol with racemic albuterol in patients ages 2 to 14 years with acute asthma who presented to the pediatric emergency department (ED). Patients were enrolled if they had moderate or severe symptoms documented by a previously validated clinical asthma score greater than 8 or a forced expiratory volume in 1 second (FEV1) less than 70% of predicted (for those able to perform spirometry).5 After randomization, patients weighing less than 25 kg were given unit doses of 1.25 mg levalbuterol or 2.5 mg racemic albuterol, and patients heavier than or equal to 25 kg were given 2.5 mg levalbuterol or 5 mg racemic albuterol. Patients received 3 nebulized treatments at 20-minute intervals, with subsequent treatments every 30 to 60 minutes at the discretion of the attending ED physician. All patients also received oral corticosteroid therapy with the second treatment. Ipratropium bromide therapy was not given until after the third nebulized treatment. Main outcome measures included changes from the baseline clinical asthma score and FEV1, measured after the first, third, and fifth nebulizer treatments. Secondary outcomes included number of nebulized treatments until disposition, rate of hospitalization, number of adverse events, and changes over time in pulse rate, respiratory rate, and oxygen saturation. The authors calculated that to have a 90% chance of detecting a 10% difference in FEV1 between study groups, 61 children would be required in each group. (For a discussion of power calculations, see accompanying box, “Weighing the Evidence.”)There were 68 patients randomized to the racemic albuterol group and 71 to the levalbuterol group. The initial median asthma score in both groups was 10, and the median FEV1 percent predicted was 25% in the levalbuterol group and 27% in the racemic albuterol group. The groups did not differ significantly in improvement in clinical asthma score or change in FEV1 percent predicted after the first, third, or fifth treatments. No analyses were done on FEV1 differences after the fifth treatment because of the small number of subjects. In addition, there were no differences in median number of nebulizations (3 in each group), percent of patients hospitalized (11% in levalbuterol group vs. 13% in racemic albuterol group), or changes over time in pulse, respiratory rate, or pulse oximetry.Dr. Paul has disclosed no financial relationships relevant to this commentary. However, there is discussion of an unapproved/investigative use of a commercial product/device. Levalbuterol is FDA-approved for children ages 6 years and older. This study includes children ages 2 to 14 years.Many practitioners have questioned whether the much higher cost of levalbuterol is justified by any clinical advantage over the much less expensive albuterol.6 At my institution, the cost for albuterol is 32 cents for a 2.5-mg dose compared to $2.24 for a 1.25-mg dose of levalbuterol (7 times more expensive per treatment). This study of pediatric patients with moderate to severe acute asthma provides further evidence that levalbuterol has similar efficacy and offers no improvement in adverse effects when compared to albuterol. If the S-enantiomer were a cause of increased adverse effects or decreased efficacy when using racemic albuterol, then a treatment protocol such as the one used in this study, where several doses of the drug are given in a short period of time, would be more likely to uncover those effects. However, this study found no decrease in adverse effects or improvement in primary outcome measures among patients who received levalbuterol compared to those who received racemic albuterol. Unless severe adverse effects develop with the use of racemic albuterol, levalbuterol may not be worth the extra cost.

Effect of Helium-oxygen Atomization Inhalation in the Treatment of Infantile Acute Bronchiolis

目的 评估吸入低浓度的氦-氧混合气雾化吸入治疗毛细支气管炎的疗效.方法对25例毛细支气管炎患儿通过非重复呼吸面罩吸入10L/min含氧40%的氦-氧混合气雾化吸入喘乐宁(治疗组)或者空气-氧气雾化吸入喘乐宁(对照组).观察治疗前后患儿喘憋、紫绀、吸气三凹征、烦躁、咳嗽等症状缓解情况及肺部听诊的改变及两组治疗前和治疗后20min血气分析的比较.使用临床哮喘评分标准进行治疗前后的临床评价.结果治疗组和对照组治疗前后临床哮喘评分都有降低,两组治疗结果相比有明显差异.与对照组相比,使用氦-氧作雾化吸入患儿PaO2、PaCO2、pH改善更为明显.结论使用氦-氧雾化吸入能将更多支气管舒张药物带到小气道,降低小气道的阻力,改善临床症状及血气指标,比常规氧气雾化吸入更加迅速有效,在治疗中-重度毛细支气管炎时可先使用氦-氧雾化吸入支气管扩张药物改善症状,降低气管插管率。

Electromyographic monitoring of respiratory muscle activity in dyspneic infants and toddlers

The aim of this study was to investigate whether the changes that occurred in the clinical asthma score (CAS) correlated with the changes in the respiratory electromyographic (EMG) activity over the days during admission to hospital in dyspneic infants and toddlers. Sixteen infants and toddlers (9 males) were studied during admission and 7 days after discharge. The CAS was used to assess the severity of dyspnea and consists of five items: respiration rate, wheezing, retractions, observed dyspnea, and inspiration-to-expiration ratio. Each item was scaled 0, 1, or 2, with a maximum score of 10. Electrical activity from the diaphragm (di) and intercostal muscles (int) was derived from surface electrodes. The logarithm of the EMG-Activity-Ratio (log EMGAR; ratio of mean peak-to-bottom EMG activity during admission to the hospital, to that at baseline, 7 days after discharge) was used as EMG parameter. For assessing the association between the repeated observations of the CAS and the EMG measurements we used the quantity r2 obtained with analysis of covariance. On the day of admission the patients had a mean CAS of 5.9 +/- 1.2. On the day of discharge the mean CAS decreased significantly to 2.1 +/- 1.6, indicating that the CAS returned to normal values. In line with this observation, a significant decrease in the log EMGARdi and log EMGARint was observed during the stay in the hospital. Over all subjects the correlation coefficient (r) of log EMGARdi versus CAS was 0.71, log EMGARint versus CAS was 0.67, and the mean log EMGAR versus CAS was 0.75 (p < 0.01, for all values). The correlation coefficients of subjects of < or = 1 year seemed to be lower than those of subjects of > 1 year of age (p < 0.01) and female subjects showed higher correlation coefficients than males. This study showed a moderate, but significant, relationship between the changes that occurred in the CAS and the changes in respiratory EMG activity during admission to hospital in dyspneic infants and toddlers. Moreover, the correlation coefficients of the combined leads of the intercostals and diaphragm (mean log EMGAR) were higher than those of the separate leads. The EMG measurements would extend diagnostic possibilities and would provide an objective measure to evaluate the clinical course of the disease and the efficacy of therapy in infants and toddlers with recurrent wheezing disorders.

Clinical Efficacy of Racemic Albuterol Versus Levalbuterol for the Treatment of Acute Pediatric Asthma

An efficacy treatment study is conducted comparing levalbuterol to racemic albuterol for acute pediatric asthma in the emergency department (ED). This was a prospective, double-blind, randomized, controlled study involving 129 children (2 to 14 years), presenting to a pediatric ED with an acute moderate or severe asthma exacerbation. Children were treated using a standard ED asthma pathway. Primary outcomes were changes from baseline in clinical asthma score and the percentage of predicted forced expiratory volume in 1 second after the first, third, and fifth treatment. Secondary outcomes included number of treatments, length of ED care, rate of hospitalization, and changes in pulse rate, respiratory rate, and oxygen saturation. Occurrence of adverse events was recorded. Sixty-four children in the racemic albuterol and 65 children in the levalbuterol group completed the study. There were no differences between groups in primary outcomes, secondary outcomes, or adverse events. There was no difference in clinical improvement in children with acute moderate to severe asthma exacerbations treated with either racemic albuterol or levalbuterol.

Theophylline versus terbutaline in treating critically ill children with status asthmaticus: A prospective, randomized, controlled trial

To compare the efficacy of theophylline, terbutaline, or theophylline combined with terbutaline treatment in critically ill children with status asthmaticus who are already receiving continuous nebulized albuterol and intravenous corticosteroids. Randomized, prospective, controlled, double-blind trial. Pediatric intensive care unit of a tertiary-care children's medical center. Forty critically ill children between the ages of 3 and 15 yrs with impending respiratory failure secondary to status asthmaticus. All patients received intravenous methylprednisolone and continuous nebulized albuterol. The three study groups received theophylline plus placebo (group 1), terbutaline plus placebo (group 2), or theophylline and terbutaline together (group 3). Differences in baseline characteristics, change in clinical asthma score over time, length of pediatric intensive care unit stay, and incidence of adverse events were determined. The three study groups were similar in age, gender, race, asthma severity, and treatment. There were no differences in clinical asthma score over time, length of pediatric intensive care unit stay, or incidence of adverse events between the three groups, with the exception of a higher incidence of nausea in children in group 3. The median hospital cost of medication and theophylline blood levels was significantly lower in group 1 compared with groups 2 and 3 (280 US dollars vs. 3,908 US dollars vs. 4,045 US dollars, respectively, p < .0001). Theophylline, when added to continuous nebulized albuterol therapy and intravenous corticosteroids, is as effective as terbutaline in treating critically ill children with status asthmaticus. The addition of theophylline to baseline therapy is more cost-effective when compared with terbutaline alone or terbutaline and theophylline together. Theophylline should be considered for use early in the management of critically ill asthmatic children.

A Modified Pulmonary Index Score with predictive value for pediatric asthma exacerbations

Several clinical asthma scores have been derived from combinations of physical findings in pediatric asthmatic patients. To test the reproducibility and validity of one such score, the Modified Pulmonary Index Score (MPIS), and to evaluate its predictive value in children hospitalized for asthma. In the MPIS, 6 categories are evaluated: oxygen saturation, accessory muscle use, inspiratory to expiratory flow ratio, degree of wheezing, heart rate, and respiratory rate. For each of these 6 measurements or observations, a score of 0 to 3 is assigned. To evaluate the reproducibility of the MPIS, inpatients with status asthmaticus were examined by an attending physician, nurse, and respiratory therapist who were blinded to the other observers' scores. To evaluate the validity of the MPIS as a scale of severity of illness in asthmatic patients, the score at admission was compared with selected outcomes in the same patients. A total of 30 patients participated in this study (mean +/- SD age, 7.6 +/- 5.5 years). Our finding revealed that the MPIS is highly reproducible with a high degree of interrater reliability across caregiver groups (physician to nurse: r = 0.98; 95% confidence interval [CI], >0.96; physician to respiratory therapist: r = 0.95; 95% CI, >0.92; nurse to respiratory therapist: r = 0.94; 95% CI, >0.90). The admission MPIS positively correlated with intensive care unit admission (P < .001), days of continuous albuterol therapy (P = .002), days of supplemental oxygen (P = .002), and length of hospital stay (P = .004). The MPIS is a highly reproducible and valid indicator of severity of illness in children with asthma. To our knowledge, this is the first pediatric clinical asthma score demonstrated to be reproducible across groups of health care professionals who treat pediatric patients with asthma.

Asthma severity scores for preschoolers displayed weaknesses in reliability, validity, and responsiveness

Objective To evaluate the measurement properties of asthma severity scores for use in preschool children. Methods A Medline search was used to identify published asthma severity scores for use in preschool children. The measurement properties of the scores (item development, reliability, validity, responsiveness, and usability) were evaluated using a published framework. Results Ten asthma severity scores were identified, with 19 different clinical variables used as items. Interrater agreement was assessed by five scores. Only two scores—Clinical Asthma Score (CAS) and Respiratory Distress Assessment Index (RDAI)—reported good agreement based on weighted κ-statistics (0.64–0.90). Construct validity was reported by the CAS, Clinical Asthma Evaluation Score (CAES), the Clinical Symptom Grading System (CSGS), and the Preschool Respiratory Assessment Measure (PRAM). Correlation coefficients between asthma severity scores and clinical measures (length of stay, drug dosing interval, O 2 saturation, health professional assessment, PaO 2, PaCO 2) ranged from 0.47 to 0.70. Responsiveness was formally demonstrated for two scales (PRAM, CAS). Conclusions Most asthma severity scales for use in preschool children have been informally developed. Recently developed scores (CAS, PRAM) have more rigorously evaluated their measurement properties. Research is needed to directly compare the asthma severity scores developed for use in preschool children.

Prediction of asthma admission using the newly developed Siriraj clinical asthma score (SCAS) compared to Wood's and Parkin's score

Rationale Since the assessment of acute asthma severity with previously developed asthma score results in a significant interpersonal variation, we developed SCAS for prediction of hospitalization compared to Wood's and Parkin's score. Methods Asthmatic patients under 12 years of age presented to the emergency room or out patient department (OPD), with acute asthmatic attack were enrolled. SCAS assessing wheezing, respiratory rate, chest retraction, dyspnea and oxygen saturation in room air were recorded along with Wood's and Parkin's score before and after each bronchodilator nebulization until the patients were discharged or admitted to the hospital. Results Seventy patients were enrolled. Fourteen percent of them were admitted with SCAS ≥9, Wood's score ≥6, Parkin's score ≥8. Wood's score have high accuracy at ≥6, high specificity at ≥7. Parkin's score have high accuracy at ≥8 high specificity at ≥9, SCAS have high accuracy at ≥9 high specificity at ≥10. All of the items have a good interpersonal reliability except I:E ratio (weighted kappa (Kw)=0.28, 95%CI=0.01,0.54), Air entry (Kw=0.78, 95%CI=0.49,1.00) and breath sounds (Kw=0.63, 95%CI=0.34,0.91). All items except conscious change, cyanosis and I:E ratio were correlated well with nebulization used (P-value<0.01). For intraclass correlation, SCAS have a highest value (1). Conclusions SCAS score have a good predictability of asthma admission with a good interpersonal reliability. Score's value have a good validity of a prediction of nebulization used.

A Modified Pulmonary Index Score With Predictive Value for Pediatric Asthma Exacerbation

Background: Several clinical asthma scores have been derived from combinations of physical findings in pediatric asthmatic patients. Objective: To test the reproducibility and validity of one such score, the Modified Pulmonary Index Score (MPIS), and to evaluate its predictive value in children hospitalized for asthma. Methods: In the MPIS, 6 categories are evaluated: oxygen saturation, accessory muscle use, inspiratory to expiratory flow ratio, degree of wheezing, heart rate, and respiratory rate. For each of these 6 measurements or observations, a score of 0 to 3 is assigned. To evaluate the reproducibility of the MPIS, inpatients with status asthmaticus were examined by an attending physician, nurse, and respiratory therapist who were blinded to the other observers’ scores. To evaluate the validity of the MPIS as a scale of severity of illness in asthmatic patients, the score at admission was compared with selected outcomes in the same patients. Results: A total of 30 patients participated in this study (mean SD age, 7.6 5.5 years). Our finding revealed that the MPIS is highly reproducible with a high degree of interrater reliability across caregiver groups (physician to nurse: r 0.98; 95% confidence interval [CI], 0.96; physician to respiratory therapist: r 0.95; 95% CI, 0.92; nurse to respiratory therapist: r 0.94; 95% CI, 0.90). The admission MPIS positively correlated with intensive care unit admission (P .001), days of continuous albuterol therapy (P .002), days of supplemental oxygen (P .002), and length of hospital stay (P .004). Conclusions: The MPIS is a highly reproducible and valid indicator of severity of illness in children with asthma. To our knowledge, this is the first pediatric clinical asthma score demonstrated to be reproducible across groups of health care professionals who treat pediatric patients with asthma. Ann Allergy Asthma Immunol. 2005;94:355–359.

Efficacy of IV Theophylline in Children with Severe Status Asthmaticus

Purpose of the Study. To determine if the addition of intravenous (IV) theophylline to an aggressive treatment regimen of inhaled and IV beta-agonists, inhaled ipratroprium and IV methylprednisolone would enhance the recovery of children with severe status asthmaticus admitted to the pediatric intensive care unit (PICU).Study Population. Forty-seven children with a diagnosis of status asthmaticus who were admitted to the Cardinal Glennon Children’s Hospital in St Louis PICU for ≤2 hours. All subjects were in severe distress with a modified Wood-Downes clinical asthma score (CAS) of ≥5. Subjects’ age range was 13 months to 17 years.Methods. Subjects were enrolled who fulfilled the above criteria. In brief, the CAS includes measures of oxygenation, breath sounds, accessory muscle use, expiratory wheezing, and cerebral function. Admission to the PICU was determined by inadequate response to repeated albuterol treatments and the ED and critical care staff. Subjects were randomly assigned to receive in addition to their regular aggressive treatment (denoted above in purpose of study) either IV aminophylline 7 mg/kg loading dose followed by age adjusted rates of 0.5–0.65 mg/kg/hr or no additional treatment (controls). Theophylline levels were kept between 12 to 17 μg/mL. The CAS evaluations were performed by investigators blinded to the treatment and were performed twice daily by 1 of 4 investigators. The PICU attending and resident team were all aware of the treatment assignment and made all medical decisions related to the subjects. CAS was suspended in the event of intubation and resumed on extubation. Nursing staff was queried regarding side effects of the subjects.Results. There was no significant difference between the theophylline and control groups with respect to age, sex, race, home medications, past use of hospital resources, origin (ED or ward), ED treatment, or time of admission. The baseline CAS scores were not different. Six subjects required mechanical ventilation (3 in each group), although the 3 control subjects were intubated after treatment and the 3 in the theophylline group before treatment was begun. Subjects receiving IV theophylline had a significant decrease in time to reach CAS ≤3 and a greater percentage change in respiratory rate than control subjects during the first 12 hours in the PICU. Theophylline did not significantly influence the time to meet PICU discharge criteria among patients not receiving mechanical ventilation, but in those requiring intubation, the PICU stay was reduced. There was no significant difference in adverse effects between the 2 groups, except and increase in complaints of emesis in the theophylline group and increase in tremor in the control group.Conclusions. Contrary to the National Heart Lung and Blood Institute guidelines for treatment of status asthmaticus in children, this study suggests that critically ill children with severe status asthmaticus may benefit from the addition of IV theophylline to β-agonist, anticholinergic, and corticosteroid therapies. Additional studies may examine the administration of theophylline to select patients in the ED unresponsive to conventional therapy or in patients known to be high risk for respiratory failure.Reviewer’s Comments. This is the first prospective randomized trial of IV theophylline limited to children admitted to the PICU. Other studies in hospitalized (noncritical care) asthmatic children failed to show a benefit with the addition of theophylline to conventional treatment. It is possible that the benefit of the addition of theophylline is dependent on the severity of their illness. Adult studies have shown the improvement in spirometry with the addition of a methylxanthine is related to the degree of airway narrowing. The addition of theophylline may serve to reduce the incidence of respiratory failure and mechanical ventilation in children with severe status asthmaticus. The authors note that not blinding the medical team to the treatment may have influenced the results to some degree, but for safety reasons, they did not feel that was warranted. The authors referred to this as a “controlled” study, but there was no reference to a placebo (ex: saline). It would be interesting to repeat this study with a placebo control and with some of the newer critical care treatments such as heliox.

Inter-rater evaluation of a clinical scoring system in children with asthma

Many clinical scores that measure the degree of asthma are used without adequate evaluation of inter-rater reliability. When reliability is tested, most often the Cohen K statistic is used, which limits the comparative results of only two raters at a time. To evaluate inter-rater agreement of a clinical asthma score using a multi-rater K statistic. Four raters administered a clinical asthma score to 17 children with clinical asthma. Five items were evaluated: O2 requirement, inspiratory breath sounds, accessory muscle use, expiratory wheeze, and cerebral function. For each, a score of zero indicated a normal state; one, moderate impairment; two, severe impairment. A multi-rater kappa statistic was used as a measure of agreement among all four raters simultaneously. This was applied using hand calculations then cross-checked by using a standard statistical syntax, a component of the Statistical Package for Social Sciences (SPSS 9.0). Application of the multi-rater K statistic revealed strong agreement among raters on oxygenation (K = 0.759), moderate agreement for expiratory wheeze and cerebral function (K = 0.698), and poor agreement for accessory muscle use (K = 0.528) and inspiratory breath sounds (K = 0.316). The level of agreement varied by item with the least subjective item, O2 requirement, demonstrating the highest inter-rater correlation. A multi-rater kappa statistic can be applied to data obtained from a clinical scoring instrument either manually or by using statistical syntax provided by SPSS.

Validity, predictability and repeatability of the two clinical asthma scoring systems in asthmatic children admitted to the siriraj hospital

Validity, predictability and repeatability of the two clinical asthma scoring systems in asthmatic children admitted to the siriraj hospital