Pediatric Asthma Exacerbations Research Articles

Nasal oxidative stress mediating the effects of colder temperature exposure on pediatric asthma symptoms.

Colder temperature exposure is a known trigger for pediatric asthma exacerbation. The induction of oxidative stress is a known pathophysiologic pathway for asthma exacerbation. However, the role of oxidative stress in linking colder temperature exposure and worsened pediatric asthma symptoms is poorly understood. In a panel study involving 43 children with asthma, aged 5-13 years old, each child was visited 4 times with a 2-week interval. At each visit, nasal fluid, urine, and saliva samples were obtained and measured for biomarkers of oxidative stress in the nasal cavity (nasal malondialdehyde [MDA]), the circulatory system (urinary MDA), and the oral cavity (salivary MDA). Childhood Asthma-Control Test (CACT) was used to assess asthma symptoms. When ambient daily-average temperature ranged from 7 to 18 °C, a 2 °C decrement in personal temperature exposures were significantly associated with higher nasal MDA and urinary MDA concentrations by 47-77% and 6-14%, respectively. We estimated that, of the decrease in child-reported CACT scores (indicating worsened asthma symptoms and asthma control) associated with colder temperature exposure, 14-57% were mediated by nasal MDA. These results suggest a plausible pathway that colder temperature exposure worsens pediatric asthma symptoms partly via inducing nasal oxidative stress. The role of oxidative stress in linking colder temperature exposure and worsened asthma symptoms is still poorly understood. Lower temperature exposure in a colder season was associated with higher nasal and systemic oxidative stress in children with asthma. Nasal MDA, a biomarker of nasal oxidative stress, mediated the associations between colder temperature exposures and pediatric asthma symptoms. The results firstly suggest a plausible pathway that colder temperature exposure worsens pediatric asthma symptoms partly via inducing oxidative stress in the nasal cavity.

A Quality Improvement Initiative to Minimize Unnecessary Chest X-Ray Utilization in Pediatric Asthma Exacerbations.

Current national guidelines recommend against chest X-rays (CXRs) for patients with acute asthma exacerbation (AAE). The overuse of CXRs in AAE has become a concern, prompting the need for a quality improvement (QI) project to decrease CXR usage through guideline-based interventions. We aimed to reduce the percentage of CXRs not adhering to national guidelines obtained for pediatric patients presenting to the Emergency Department (ED) with AAE by 50% within 12 months of project initiation. We conducted this study at a New York City urban level-2 trauma center. The team was composed of members from the ED and pediatric departments. Electronic medical records of children aged 2 to 18 years presenting with AAE were evaluated. Monthly data on CXR utilization encompassing instances where the ordered CXR did not adhere to guidelines was collected before and after implementing interventions. The interventions included provider education, visual reminders, printed cards, grand-round presentations, and electronic medical records modifications. The study encompassed 887 eligible patients with isolated AAE. Baseline data revealed a mean preintervention CXR noncompliance rate of 37.5% among children presenting to the ED with AAE. The interventions resulted in a notable decrease in unnecessary CXR utilization, reaching 16.7%, a reduction sustained throughout subsequent months. This QI project successfully reduced unnecessary CXR utilization in pediatric AAE. A multi-faceted approach involving education, visual aids, and electronic reminders aligned clinical practice with evidence-based guidelines. This QI initiative is a potential template for other healthcare institutions seeking to curtail unnecessary CXR usage in pediatric AAE.

Analysis of guideline recommendations for treatment of asthma exacerbations in children: a Pediatric Emergency Research Networks (PERN) study

RationaleThere is significant practice variation in acute paediatric asthma, particularly severe exacerbations. It is unknown whether this is due to differences in clinical guidelines.ObjectivesTo describe and compare the content and...

Viral Infections are Associated with More Severe Clinical Outcomes During Pediatric Asthma Exacerbations

Viral Infections are Associated with More Severe Clinical Outcomes During Pediatric Asthma Exacerbations

Managing Pediatric Asthma Exacerbations: The Role of Timely Systemic Corticosteroid Administration in Emergency Care Settings-A Multicentric Retrospective Study.

Asthma is the most prevalent chronic respiratory condition in children. An asthma exacerbation (AE) is a frequent reason for emergency department (ED) visits. An important step in the management of a moderate to severe AE is the administration of systemic corticosteroids (SCS) within 1 h after ED presentation. This study aimed to determine the timing of SCS administration and correlate this with the length of stay and oxygen therapy duration and to explore factors predicting timely administration. This study used a retrospective multicenter observational design based on electronic medical records review. Children aged < 18 years, presenting to the ED with a moderate to severe AE were included. 205 patients were included. Only 28 patients received SCS within 60 min after ED arrival. The median time to SCS administration was 169 min (Q1 92-Q3 380). A correlation was found between timing and oxygen treatment duration (r = 0.363, p < 0.001) and length of stay (r = 0.368, p < 0.001). No patient characteristics predicted timely SCS administration. Three in four children who presented with a moderate to severe AE at the ED did not receive SCS within the first hour. A prolonged timing of SCS administration correlated with a prolonged length of stay and extended need for oxygen support.

The effect of urban heat islands on pediatric asthma exacerbation: How race plays a role

BackgroundClimate change disproportionately affects marginalized communities as seen with the urban heat island phenomenon. This is an example of environmental racism as it stems from past governmental policy: redlining. Environmental racism also leads to health inequities, as seen with asthma in Black communities. Studies have shown the relationship between the urban heat island phenomenon and asthma exacerbation; however, there is a gap in the data regarding racial differences and pediatric cases. The combination of urban heat, environmental racism, and asthma susceptibility creates a hazardous relationship in which Black children are at greater risk of asthma-related negative health outcomes. PurposeThe purpose of this study was to explore how the relationship between urban heat islands and pediatric asthma exacerbations differs in Black communities compared to White communities and to provide insight for policy makers in creating greater environmental and health equity. MethodsA quantitative ecologic study was conducted within the five boroughs of New York City in which the area was divided into 42 neighborhoods. Demographics, ambient air temperature, asthma emergency department (ED) visits, and covariate data were collected from various open data sources. Then, both Pearson partial correlation and a multiple linear regression were conducted utilizing IBM SPSS software. ResultsThere was a statistically significant positive correlation between asthma ED visits and percent of Black residents, r (35) = 0.41, p < .05, and a statistically significant negative correlation between asthma ED visits and the percent of White residents, r (35) = −0.44, p < .01. Similarly, multiple regression analysis showed that the percent of non-Hispanic Black residents and ambient air temperatures statistically significantly predicted the rate of asthma ED visits at F (3,38) = 22.354, p < .001. The adjusted R2 for the model was 0.61, p < .001. DiscussionBlack communities are further impacted by asthma than White communities—and it seems like it is mostly due to race and its implications, including low socioeconomic status. Additionally, providing data on the correlation between urban heat islands and pediatric asthma exacerbations has great significance. Urban populations are projected to increase to approximately 68% by 2050. With more of the population susceptible to urban heat, it is imperative to address this relationship sooner rather than later. There are also long-term effects of persistent childhood asthma relating to education, physical health, mental health, intellectual development, and maternal health. Finally, there is a notable financial impact of pediatric asthma.

Evaluation of Dexamethasone Dosing Strategies in Pediatric Asthma Exacerbations

OBJECTIVES This study aimed to determine if there is a difference in health care use in pediatric asthma exacerbations with dexamethasone at a standardized dose compared with a weight-based approach.   METHODS This was a single-center, retrospective study of patients ages 2 to 17 years presenting to the pediatric emergency department (ED) with an asthma exacerbation between July 1, 2018, and June 30, 2021. Patients who received at least 1 dose of dexamethasone and had an International Classification of Diseases, 10th revision (ICD-10) code for asthma were included. The primary end point was the rate of return visits to the ED within 30 days and 31 to 90 days. Secondary end points included incidence of hospitalization and intubation, length of stay, dexamethasone dosing discrepancies, other corticosteroids or adjunctive therapies used, and medication escalation at discharge. The incidences of vomiting, hyperglycemia, and hypertension were also evaluated. Descriptive statistics were used for categoric variables and a Kaplan-Meier survival curve and Cox regression evaluated the primary outcome. RESULTS A total of 252 patients were included, 162 in the standardized dosing group and 90 in the weight-based group. There was no difference in return visits at 30 days and 31 to 90 days (3.1 vs 4.4, p = 0.58; and 3.7 vs 7.8, p = 0.16). The standardized group had a statistically significant shorter length of stay and lower ipratropium and magnesium use compared with the weight-based group. However, hospitalization rates were lower overall in the weight-based group. The incidences of vomiting, hyperglycemia, and hypertension were similar. CONCLUSIONS A standardized dosing strategy for dexamethasone in pediatric asthma exacerbations showed favorable outcomes and may lead to improved adherence.

Incidence and causative agent distribution of viral-induced paediatric asthma exacerbations under strict infection control measures: a single-centre retrospective study in Japan

BackgroundThe prevalence of respiratory viruses in children changed under strict infection control measures during the coronavirus disease 2019 (COVID-19) outbreak. In this study, we investigated the frequency of viral detection in the nasopharynx of paediatric patients with asthma exacerbations requiring hospitalization during the COVID-19 pandemic, as well as the distribution of causative viruses.MethodsWe included paediatric patients admitted for asthma exacerbations between November 2020 and December 2022 at a single centre in Kobe, Japan. Demographic, clinical, and laboratory data were collected from their medical records and using additional questionnaires. All patients enrolled in this study met the diagnostic criteria for asthma exacerbations outlined in the Japanese Pediatric Guideline for the Treatment and Management of Bronchial Asthma 2020. Statistical differences were calculated using univariate analyses (chi-square or Mann‒Whitney U test).ResultsWe enrolled 203 children hospitalized for asthma attacks and collected nasopharyngeal samples from 189 patients. The median patient age was 3.0 years. Asthma severity was classified as mild (4.0%), moderate (82.3%), or severe (13.8%). The proportion of viral respiratory infections was 95.2% (180/189). The rate of patients with multiple viral infections was 20.6% (39/189). The most frequently detected pathogens were rhinovirus and enterovirus (RV/EV) at 69.3% (131/189), allowing for duplicate detection, followed by respiratory syncytial virus (RSV) at 28.6% (54/189). We also detected RV/EV almost every month compared to RSV and other viruses. In addition, RV/EV-positive patients were significantly older (p = 0.033), exhibited higher WBC counts (p < 0.001) and higher Eos counts (p < 0.001), had elevated total IgE levels (p < 0.001) and house dust mite-specific IgE levels (p = 0.019), had a shorter duration of hospitalization (p < 0.001), and had a shorter duration of oxygen therapy (p < 0.001). In patients positive for RV/EV, the use of ICSs significantly reduced the severity of the condition (p < 0.001).ConclusionEven under strict infection control measures, respiratory viruses were detected in the nasopharynx of almost all paediatric patients who had asthma exacerbations requiring hospitalization.

Medical and pharmacy student outcomes from an interprofessional education transitions of care simulation

Interprofessional education is a requirement for both medical and pharmacy graduate program accreditation and it prepares students to work as high functioning healthcare teams. Since patients with chronic diseases often require care from various providers across multiple healthcare settings, efficient care coordination directly correlates with improved clinical outcomes and cost savings based on prudent use of resources. This curricular resource describes outcomes from an interprofessional transitions of care simulation completed by third year medical (MD) and pharmacy (PharmD) students at the University of South Florida in 2021 and 2022. We evaluate changes in students' perceptions about working with interprofessional teams and changes in their clinical knowledge following the simulation. This simulation presented students with one of two clinical vignettes (a pediatric asthma exacerbation or an acute chest syndrome sickle cell crisis), and students progressed through patient management in the emergency room, intensive care unit, medical floor, and discharge planning. This activity was conducted via Microsoft Teams in 2021 secondary to the coronavirus pandemic, and implementation continued to be on Microsoft Teams thereafter due to its success. Student outcomes were measured with matched pre- and post-simulation surveys including nine questions regarding perceptions and knowledge. In total, 300 medical students and 261 pharmacy students participated in the surveys. Students showed statistically significant improvement in each domain, including perceived understanding of roles and abilities to work in an interprofessional environment. Cohorts benefited to similar extents both years, and interprofessional and clinical knowledge improved for both medical and pharmacy students, although not equally. This experience provides an interactive, efficient, and effective method to fulfill accreditation requirements while improving students’ perceptions of healthcare teams and their ability to clinically manage a patient. The evaluation methods used in this study are available in Tables 1–3 The clinical vignettes, preparation materials, standardized patient scripts, and faculty evaluation form to guide feedback can be found in a Box Drive link provided in section eight.

Examination of disparities in prehospital encounters for pediatric asthma exacerbations.

There are disparities in multiple aspects of pediatric asthma care; however, prehospital care disparities are largely undescribed. This study's objective was to examine racial and geographic disparities in emergency medical services (EMS) medication administration to pediatric patients with asthma. This is a substudy of the Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial, which includes data from pediatric asthma patients ages 2-18 years. We examined rates of EMS administration of systemic corticosteroids and inhaled bronchodilators by patient race. We geocoded EMS scene addresses, characterized the locations' neighborhood-based conditions and resources relevant to children using the Child Opportunity Index (COI) 2.0, and analyzed associations between EMS scene address COI with medications administered by EMS. A total of 765 patients had available racial data and 825 had scene addresses that were geocoded to a COI. EMS administered at least 1 bronchodilator to 84.7% (n=492) of non-White patients and 83.2% of White patients (n=153), P=0.6. EMS administered a systemic corticosteroid to 19.4% (n=113) of non-White patients and 20.1% (n=37) of White patients, P=0.8. There was a significant difference in bronchodilator administration between COI categories of low/very low versus moderate/high/very high (85.0%, n=485vs. 75.9%, n=192, respectively, P=0.003). There were no racial differences in EMS administration of medications to pediatric asthma patients. However, there were significantly higher rates of EMS bronchodilator administration for encounters in low/very low COIs. That latter finding may reflect inequities in asthma exacerbation severity for patients living in disadvantaged areas.

Effectiveness of a Vendor Predictive Model for the Risk of Pediatric Asthma Exacerbation: A Difference-in-Differences Analysis.

Asthma is a common cause of morbidity and mortality in children. Predictive models may help providers tailor asthma therapies to an individual's exacerbation risk. The effectiveness of asthma risk scores on provider behavior and pediatric asthma outcomes remains unknown. Determine the impact of an electronic health record (EHR) vendor-released model on outcomes for children with asthma. The Epic Systems Risk of Pediatric Asthma Exacerbation model was implemented on February 24, 2021, for volunteer pediatric allergy and pulmonology providers as a noninterruptive risk score visible in the patient schedule view. Asthma hospitalizations, emergency department (ED) visits, or oral steroid courses within 90 days of the index visit were compared from February 24, 2019, to February 23, 2022, using a difference-in-differences design with a control group of visits to providers in the same departments. Volunteer providers were interviewed to identify barriers and facilitators to model use. In the intervention group, asthma hospitalizations within 90 days decreased from 1.4% (54/3,842) to 0.7% (14/2,165) after implementation with no significant change in the control group (0.9% [171/19,865] preimplementation to 1.0% [105/10,743] post). ED visits in the intervention group decreased from 5.8% (222/3,842) to 5.5% (118/2,164) but increased from 5.5% (1,099/19,865) to 6.8% (727/10,743) in the control group. The adjusted difference-in-differences estimators for hospitalization, ED visit, and oral steroid outcomes were -0.9% (95% confidence interval [CI]: -1.6 to -0.3), -2.4% (-3.9 to -0.8), and -1.9% (-4.3 to 0.5). In qualitative analysis, providers understood the purpose of the model and felt it was useful to flag high exacerbation risk. Trust in the model was calibrated against providers' own clinical judgement. This EHR vendor model implementation was associated with a significant decrease in asthma hospitalization and ED visits within 90 days of pediatric allergy and pulmonology clinic visits, but not oral steroid courses.

Predicting pediatric severe asthma exacerbations: an administrative claims-based predictive model

Objective Previous machine learning approaches fail to consider race and ethnicity and social determinants of health (SDOH) to predict childhood asthma exacerbations. A predictive model for asthma exacerbations in children is developed to explore the importance of race and ethnicity, rural-urban commuting area (RUCA) codes, the Child Opportunity Index (COI), and other ICD-10 SDOH in predicting asthma outcomes. Methods Insurance and coverage claims data from the Arkansas All-Payer Claims Database were used to capture risk factors. We identified a cohort of 22,631 children with asthma aged 5–18 years with 2 years of continuous Medicaid enrollment and at least one asthma diagnosis in 2018. The goal was to predict asthma-related hospitalizations and asthma-related emergency department (ED) visits in 2019. The analytic sample was 59% age 5–11 years, 39% White, 33% Black, and 6% Hispanic. Conditional random forest models were used to train the model. Results The model yielded an area under the curve (AUC) of 72%, sensitivity of 55% and specificity of 78% in the OOB samples and AUC of 73%, sensitivity of 58% and specificity of 77% in the training samples. Consistent with previous literature, asthma-related hospitalization or ED visits in the previous year (2018) were the two most important variables in predicting hospital or ED use in the following year (2019), followed by the total number of reliever and controller medications. Conclusions Predictive models for asthma-related exacerbation achieved moderate accuracy, but race and ethnicity, ICD-10 SDOH, RUCA codes, and COI measures were not important in improving model accuracy.

Extreme temperature and storm exacerbations of pediatric asthma: evidence and prevention strategies

Abstract Introduction:&amp;#xD;Asthma is the most common chronic disease in children and a main cause of hospitalizations, with substantial costs to patients, families, and society. Existing disparities in asthma will likely be impacted by the increasing adverse consequences of climate change and the disproportionate impact on low-income and minority communities. Increased extreme temperatures, weather events, air pollution, and allergens linked to climate change exacerbate pediatric asthma. There is a need for greater understanding of the climate change-related risk factors specifically impacting pediatric asthma exacerbations, increased attention to health disparities, and development of strategies for prevention and management. This perspective piece describes selected research on temperature and storm-related asthma exacerbations in children and includes a discussion on possible mechanisms for weather phenomena and climate change associations, research gaps, and possible solutions related to secondary prevention.

Airway transcriptome networks identify susceptibility to frequent asthma exacerbations in children

Frequent asthma exacerbators, defined as those experiencing more than 1 hospitalization in a year for an asthma exacerbation, represent an important subgroup of individuals with asthma. However, this group remains poorly defined and understudied in children. Our aim was to determine the molecular mechanisms underlying asthma pathogenesis and exacerbation frequency. We performed RNA sequencing of upper airway cells from both frequent and nonfrequent exacerbators enrolled in the Ohio Pediatric Asthma Repository. Through molecular network analysis, we found that nonfrequent exacerbators display an increase in modules enriched for immune system processes, including type 2 inflammation and response to infection. In contrast, frequent exacerbators showed expression of modules enriched for nervous system processes, such as synaptic formation and axonal outgrowth. These data suggest that the upper airway of frequent exacerbators undergoes peripheral nervous system remodeling, representing a novel mechanism underlying pediatric asthma exacerbation.

Role of social determinants of health in differential respiratory exposure and health outcomes among children

BackgroundAttributes defining the Social Determinants of Health (SDoH) are associated with disproportionate exposures to environmental hazards and differential health outcomes among communities. The dynamics between SDoH, disproportionate environmental exposures, and differential health outcomes are often specific to micro-geographic areas.MethodsThis study focused on children less than 20 years of age who lived in Douglas County, Nebraska, during 2016–2019. To assess the role of SDoH in differential exposures, we evaluated the association between SDoH metrics and criteria pollutant concentrations and the association between SDoH and pediatric asthma exacerbations to quantify the role of SDoH in differential pediatric asthma outcomes. The Bayesian Poisson regression model with spatial random effects was used to evaluate associations.ResultsWe identified significant positive associations between the annual mean concentration of criteria pollutants (carbon monoxide, particulate matter2.5, nitrogen dioxide, sulfur dioxide) with race (Non-Hispanic Black and Hispanic/Latino), financial stability, and literacy. Additionally, there were significant positive associations between higher rates of pediatric asthma emergency department visits and neighborhoods with more Non-Hispanic Black children, children without health insurance coverage, and households without access to a vehicle.ConclusionsNon-Hispanic Black and Hispanic/Latino children living in Douglas County, NE experience disproportionately higher exposure to criteria pollutant concentrations. Additionally, higher rates of asthma exacerbations among Non-Hispanic Black children could be due to reduced access to respiratory care that is potentially the result of financial instability and vehicle access. These results could inform city planners and health care providers to mitigate respiratory risks among these higher at-risk populations.

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.

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.

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.

COVID-19 Pandemic-Related Reductions in Pediatric Asthma Exacerbations Corresponded With an Overall Decrease in Respiratory Viral Infections

COVID-19 Pandemic-Related Reductions in Pediatric Asthma Exacerbations Corresponded With an Overall Decrease in Respiratory Viral Infections

Prehospital Pediatric Asthma Care during COVID-19: Changes to EMS Treatment Protocols and Downstream Clinical Effects

Introduction During the COVID-19 pandemic, many emergency medical services (EMS) agencies modified treatment guidelines for clinical care and standard operating procedures. For the prehospital care of pediatric asthma exacerbations, modifications included changes to bronchodilator administration, systemic corticosteroid administration, and introduction of alternative medications. Since timely administration of bronchodilators and systemic corticosteroids has been shown to improve pediatric asthma clinical outcomes, we investigated the association of COVID-19 protocol modifications in the prehospital management of pediatric asthma on hospital admission rates and emergency department (ED) length-of-stay. Methods This is a multicenter, retrospective, observational cohort study comparing prehospital pediatric asthma patients treated by EMS clinicians from four EMS systems before and after implementation of COVID-19 interim EMS protocol modifications. We included children ages 2–18 years who were treated and transported by ground EMS for respiratory-related prehospital primary complaints, and who also had asthma-related ED discharge diagnoses. Patient data and outcomes were compared from 12 months prior to and 12 months after the implementation of interim COVID-19 prehospital protocol modifications using univariate and multivariable statistics. Results A total of 430 patients met inclusion criteria with a median age of 8 years. There was a slight male predominance (57.9%) and the majority of patients were African American (78.4%). There were twice as many patients treated prior to the COVID-19 protocol modifications (N = 287) compared to after (N = 143). There was a significant decrease in EMS bronchodilator administration from 76% to 59.4% of patients after COVID-19 protocol guidelines were implemented (p < 0.0001). Mixed effects models for hospital admission (to both pediatric inpatient units and pediatric intensive care units) as well as ED length-of-stay did not show any significant effect after the COVID-19 protocol change period (p = 0.18 and p = 0.55, respectively). Conclusions Despite a decrease in prehospital bronchodilator administration after COVID-19 changes to prehospital pediatric asthma management protocols, hospital admission rates and ED length-of-stay did not significantly increase. However, this finding is tempered by the marked decrease in study patients treated after COVID-19 prehospital protocol modifications. Given the potential for future waves of COVID-19 variants, further studies with larger patient populations are warranted.