Pediatric Asthma Management Research Articles

Pharmaceutical Treatment of Asthma in Children

The present review article gives an overview of the present treatment modalities of asthma during childhood and discusses the existing controversies in asthma treatment. Present guidelines of asthma treatment concentrate on treatment for adults and only marginally concern treatment of childhood asthma. The few exceptions are the British Scottish guidelines and the Nordic guidelines, which have separate paragraphs on paediatric asthma management. The main controversy in paediatric asthma treatment is that how early (in age) and how soon (after diagnosis of asthma has been established) should inhaled steroids be instituted. Does treatment with early inhaled steroids influence lung development? Also possible side effects of inhaled steroids as possible impact upon growth and effect upon the hypothalamic adrenal axis are discussed. What is the place of leukotriene antagonists in childhood asthma treatment? Other issues discussed are prevention of asthma (primary, secondary and tertiary) in relationship to treatment of asthma. Primary prevention regards preventive measures to be taken to prevent initial allergic diseases; secondary prevention aims at preventing development of further allergic disease after the initial allergic disorder, as preventing debut of asthma after atopic eczema. Tertiary prevention aims at reducing already existing allergic illness and preventing further progression. For asthma, tertiary prevention regards treatment. During later years, there has been a focus on the respiratory tract as a continuum, and how allergic rhinitis and asthma should be treated when they are coexistent. Treating exercise induced asthma optimally is regarded as an important aim in the general treatment of asthma in childhood. Particularly in childhood asthma, compliance (concordance) with treatment is an important issue. Also some controversial aspects of acute asthma treatment in young children are discussed.

Children With Asthma

According to the Centers for Disease Control and Prevention (CDC), asthma is a growing health problem in the United States; there are now 9 million children under the age of 18 diagnosed with this illness. As a chronic illness, asthma has a major impact on the life of the individual as well as the family. This article illustrates the process of incorporation of standardized guidelines for the management of pediatric asthma through the collaborative efforts of the nurse, family, and child. Inclusion of a written asthma management plan that is client specific can help to ensure successful management of this common and deadly childhood illness. It is essential that nurses focus on educating the families of children with asthma in an effort to assist them in managing this chronic illness. A case study approach is used to illustrate the complexity of the problem and facilitate the nurse's understanding of the process of assessment of need.

Implementation of Evidence Based Guidelines for Paediatric Asthma Management in a Teaching Hospital

Massie J, Efron D, Cerritelli B, et al. Arch Dis Child. 2004;89:660–664To evaluate a systemic and coordinated approach to the development and implementation of evidence-based asthma guidelines for a pediatric hospital.This was a comparative study conducted at the Royal Children’s Hospital in Melbourne, Australia. There were 3 cohorts of children evaluated between the ages of 2 and 18 years who presented with acute asthma to the emergency department. Cohort 1 presented before the development of asthma guidelines, cohort 2 was recruited to assess the effectiveness of guideline implementation, and cohort 3 was recruited 1 year later to assess the sustainability of guideline changes.The Royal Children’s Hospital best-practice guidelines for the care of asthma were established after careful review of established national/international guidelines and consideration of evidence-based reviews in the literature. The guidelines also took into consideration recommendations from Improving Child and Adolescent Asthma Management members. There was a detailed launch of the guidelines in the institution, with a major focus on implementation of the guideline recommendations through a variety of vectors. The primary outcome measures of this study were rates of reattendance and readmission to the hospital, a change in asthma morbidity, and quality of life.There were 374 children in cohort 1, 363 in cohort 2, and 377 in cohort 3. There was no difference in baseline characteristics between the cohorts (age, gender, asthma severity). There was no statistically significant difference in the proportion of patients who revisited the emergency department or were admitted to the hospital between the 3 groups within 6 months of the initial presentation (21–27% for revisits to the emergency department and 11% rehospitalization). There also were no differences in measures of morbidity between the cohorts across 3 domains (interval symptoms, exercise compromise, and bronchodilator usage) or in parent or child quality-of-life scores between the groups. However, there was a significant increase in those who were given asthma-management plans with the implementation of the practice guidelines.The implementation of evidence-based guidelines made no difference in readmission to the hospital, return visits to the emergency department, asthma morbidity, or quality of life but did increase the provision of asthma-management plans. The authors concluded that future efforts to improve asthma management should target specific components of asthma care.Certainly the results of this study are disappointing, especially for those of us who develop, implement, advocate, and teach guidelines. Were the guidelines at fault? Were the guidelines implemented properly? Were they carried through for both sides of the illness, and if so, for how long? It was not clear what went on after the first encounter. Was there appropriate follow-up with guideline-savvy primary caretakers who were able to emphasize the guidelines? My guess is that perhaps more emphasis and more “implementation” is needed more frequently at the patient/caretaker level, and I would not give up on guidelines just yet.

Pediatric Asthma Management in the Family Context: The Family Asthma Management System Scale

To examine psychometric properties of a revised version of the Family Asthma Management System Scale (FAMSS), a clinical interview to assess asthma management. The FAMSS was administered to 115 children with asthma and their primary caregivers, along with a measure of asthma morbidity. A subset of families (n = 53) participated also in objective-adherence monitoring and completed measures of asthma knowledge and self-efficacy. The FAMSS demonstrated good internal consistency (alpha = .84). The FAMSS summary score was unrelated to age, gender, race, or minority status, but was related to socioeconomic status (SES) and to functional morbidity at baseline and prospectively. Convergent validity of the FAMSS was documented. The FAMSS explained additional variance in concurrent-asthma morbidity beyond self-reports or objective adherence monitoring. The FAMSS is a valuable tool to assess family-based asthma management that addresses gaps in available assessment methodologies and holds promise for research and clinical applications.

Developing a paediatric asthma review pro forma

Accurate record keeping can enhance patient care by promoting continuity and consistency of management, and aid evaluation of clinical practice. To improve paediatric asthma management, the paediatric respiratory team in a large district general hospital developed a pre-printed asthma review sheet (pro forma) for use at asthma follow-up clinics in the paediatric outpatient department. To assess the pro forma's effectiveness, the team examined the quality of clinical documentation during a retrospective audit of entries in the case notes of 100 patients, and compared it with that in 100 completed pro formas. The completed pro formas contained information on general progress, symptom severity and management of the child since the last medical review. The pro forma was shown to improve overall documentation. It not only aided the collection of relevant, clinically useful information, thereby helping clinicians to make decisions on management regimens, but it, also proved to be a valuable assessment tool for the management of chronic asthma in children.

Emergency department management of pediatric asthma

For the physician providing acute care for children, knowledge of optimal management of pediatric asthma is essential. Asthma is one of the most common diseases of childhood, with a prevalence rate of 5.4% in the pediatric population, accounting for 17% of pediatric encounters in US emergency departments. Asthma is characterized by bronchial hyperreactivity, airway inflammation, and reversible airway obstruction. New developments in the understanding of the underlying physiology and pharmacologic treatment of pediatric asthma have occurred in recent years. Although inhaled beta-adrenergic agonists remain the initial treatment of choice for acute bronchospasm in asthma, there is increased understanding of the importance of inflammation in the disease process. There is also recognition of the role of cholinergic-mediated airway obstruction. This review focuses on the clinical applications of these concepts in the emergency management of pediatric asthma, the role of newer treatment modalities, and the value of implementing an emergency department management protocol.

Implementation of evidence based guidelines for paediatric asthma management in a teaching hospital

Aims: To evaluate a systematic approach to the development and implementation of evidence based asthma management guidelines. Methods: Comparative study of children (2–18 years) with acute asthma; a control cohort...

Pediatric asthma: improving management to reduce cost of care.

The economic burden of pediatric asthma is substantial, with national annual health care costs of $3 billion. Successful clinical management of asthma in children has the potential to decrease this burden by lowering the disproportionate costs of hospitalization and acute care for pediatric asthma patients. Based on increased understanding of the pathogenesis of asthma, revised guidelines were published by the National Institutes of Health in 1997 (with an update in 2002) and by the American Academy of Allergy, Asthma, and Immunology in 1999 to assist in the diagnosis and management of pediatric asthma. These guidelines emphasize the role of inflammation in asthma and recommend treatment of the underlying inflammatory process. Despite increased knowledge regarding the pathogenesis of the disease and the availability of effective anti-inflammatory agents, particularly inhaled corticosteroids, the prevalence of asthma and disease-related morbidity continues to remain high in children. Asthma interventions that include the use of guideline-recommended inhaled corticosteroid therapy and patient and caregiver education in asthma management may help to reduce asthma morbidity in children and decrease the substantial costs of pediatric asthma.

Parent-youth teamwork in pediatric asthma management

Rationale Because the transition of responsibility for asthma management from parent to youth can result in medication non-adherence, we used a randomized clinical trial to examine the effectiveness of an intervention aimed at promoting a teamwork approach and structuring parental supervision of medication use. Methods Participants included 42 rural youth (ages 9-15) who were randomly assigned to the Teamwork Intervention, Asthma Education, or Standard Care condition. The intervention consisted of 4 sessions, scheduled at approximately 2 week intervals across 2 months. A follow-up session occurred 3 months post-treatment. Adherence to inhaled corticosteroids was assessed via MDILog-II device. Outcome data were gathered on adherence and family responsibility for asthma management throughout the study. Data for asthma functional severity, spirometry readings, and parent-adolescent conflict were obtained pre-treatment, post-treatment, and follow-up, while patient satisfaction was measured at follow-up. Results Data were analyzed using a mixed design repeated measures ANOVA and Tukey's HSD post-hoc comparisons. Results indicated that the Teamwork Intervention group had significantly higher adherence rates (across different calculations) than either the Asthma Education or Standard Care conditions, which were not significantly different from one another. While patient satisfaction was high among the Teamwork Intervention group, increases in adolescent report of maternal-child conflict compared to the other groups were found. No significant group or time effects were obtained for asthma functional severity or lung functioning. Conclusions Overall results support the effectiveness and utility of the Teamwork Intervention as a means of improving medication adherence as youth begin to acquire more responsibility for their asthma management.

Pediatric asthma management programs

Pediatric asthma management programs

Tales of pediatric asthma management: family-based strategies related to medical adherence and health care utilization

ObjectivesTo examine how family management styles, garnered from parent interviews about the effect of asthma on family life, are related to medical adherence and health care utilization. Study designEighty parents with a child with asthma were interviewed. Computerized monitoring of medication use was collected every 2 months for 1 year. Parents and children completed measures of medical adherence and health care utilization at the time of the interview and at 1-year follow-up. Three categories of disease management were identified: reactive, coordinated care, and family partnerships. Group comparisons were made by using analysis of variance with medical adherence and health care utilization as dependent variables. ResultsManagement strategies revealed in the interview were distinguishable by adherence rates at the time of interview and 1 year after. Interview categories were also predictive of emergency department use at 1-year follow-up. The reactive group received a diagnosis of asthma 1 year after noting symptoms, in contrast with the other groups, who received a diagnosis within 6 months. ConclusionsThe use of semistructured interviews may reveal important information about how families manage asthma. Further work may help identify areas amenable to intervention and provide a better understanding of why some families delay treatment.

Improving adherence in children and adolescents

This issue of The Journal has two articles that address the question of medical adherence. The first is an invited commentary by Dr Bryan Lask from London, in which he discusses a new approach to improving adherence, “Motivational enhancement therapy (MET).” This approach has been tested in patients with cystic fibrosis and Lask describes the technique; we look forward to seeing more data concerning its application.The second paper is from Barbara Fiese and Frederick Wamboldt (“Tales of pediatric asthma management: family-based strategies related to medical adherence and health care utilization”). In this paper, the authors study how family management style, measured by videotaped semistructured interviews, correlates with medical adherence and use of health care resources. They describe three categories of disease management: reactive, coordinated care, and family partnerships. The families with the reactive style did worse than the other two groups, but the family partnerships did not really seem to have better outcomes than coordinated care.These papers help us to understand better how families manage chronic diseases and challenge some of our preconceptions concerning therapeutic approaches to adherence/concordance.Page 430 (Lask)Page 457 (Fiese) This issue of The Journal has two articles that address the question of medical adherence. The first is an invited commentary by Dr Bryan Lask from London, in which he discusses a new approach to improving adherence, “Motivational enhancement therapy (MET).” This approach has been tested in patients with cystic fibrosis and Lask describes the technique; we look forward to seeing more data concerning its application. The second paper is from Barbara Fiese and Frederick Wamboldt (“Tales of pediatric asthma management: family-based strategies related to medical adherence and health care utilization”). In this paper, the authors study how family management style, measured by videotaped semistructured interviews, correlates with medical adherence and use of health care resources. They describe three categories of disease management: reactive, coordinated care, and family partnerships. The families with the reactive style did worse than the other two groups, but the family partnerships did not really seem to have better outcomes than coordinated care. These papers help us to understand better how families manage chronic diseases and challenge some of our preconceptions concerning therapeutic approaches to adherence/concordance. Page 430 (Lask) Page 457 (Fiese)

Paediatric utilization of a general emergency department in a developing country

Knowledge of the spectrum and frequencies of pediatric emergencies presenting to an emergency department (ED) of individual developing countries is vital in optimizing the quality of care delivered locally. A prospective 6 wk review of all pediatric (< 18 y) attendees to an urban ED was done, with patient age, presenting complaints, diagnoses, time of arrival and disposition recorded. Complete data were available on 1172 patients, with an age range of 4 d to 18 y (mean +/- SD 6.9 +/- 5.6 y); 43% were aged < or = 4 y. The main presenting complaints were injuries (26.9%), fever (24%) and breathing difficulties (16.6%). The most common diagnosis was minor trauma (24.2%), with soft-tissue injuries predominating (80.6%). The other diagnoses were asthma (12.6%), upper respiratory infections (12.1%), other infections (12.1%) and gastroenteritis (11.8%). Equal proportions of patients were seen throughout the day. 25% of patients were admitted. Young age (< 1 y); presence of past medical history, general practitioner referrals, diagnosis of bronchiolitis and pneumonia were significantly associated with risk of admission. A wide spectrum of paediatric illnesses was seen in the ED, with an overrepresentation of young children. This supports the decision to have either a separate pediatric ED or paediatric residents on the staff. The training curricula should emphasize the management of pediatric trauma, infections and asthma. Alternatively, developing guidelines for the five most common presenting complaints would account for 82% of all attendees and could be directed towards all staff on the ED.

Paediatric utilization of a general emergency department in a developing country

Aim: Knowledge of the spectrum and frequencies of paediatric emergencies presenting to an emergency department (ED) of individual developing countries is vital in optimizing the quality of care delivered locally. Methods: A prospective 6 wk review of all paediatric (&lt; 18y) attendees to an urban ED was done, with patient age, presenting complaints, diagnoses, time of arrival and disposition recorded. Results: Complete data were available on 1172 patients, with an age range of 4 d to 18 y (mean ± SD 6.9 ± 5.6 y); 43% were aged ≤4 y. The main presenting complaints were injuries (26.9%), fever (24%) and breathing difficulties (16.6%). The most common diagnosis was minor trauma (24.2%), with soft‐tissue injuries predominating (80.6%). The other diagnoses were asthma (12.6%), upper respiratory infections (12.1%), other infections (12.1%) and gastroenteritis (11.8%). Equal proportions of patients were seen throughout the day. 25% of patients were admitted. Young age (&lt;1 y); presence of past medical history, general practitioner referrals, diagnosis of bronchiolitis and pneumonia were significantly associated with risk of admission. Conclusion: A wide spectrum of paediatric illnesses was seen in the ED, with an overrepresentation of young children. This supports the decision to have either a separate paediatric ED or paediatric residents on the staff. The training curricula should emphasize the management of paediatric trauma, infections and asthma. Alternatively, developing guidelines for the five most common presenting complaints would account for 82% of all attendees and could be directed towards all staff on the ED.

Exhaled nitric oxide: A useful aide in pediatric asthma management?

Exhaled nitric oxide: A useful aide in pediatric asthma management?

Effectiveness of a Clinical Pathway for Emergency Management of Pediatric Asthma

Effectiveness of a Clinical Pathway for Emergency Management of Pediatric Asthma

Safety of the newer inhaled corticosteroids in childhood asthma.

Inhaled corticosteroids (ICS) remain a vital part of the management of persistent asthma, but concerns have been raised about their potential adverse effects in children. This review examines the safety data on three new ICS - fluticasone propionate, mometasone, and extrafine beclomethasone in hydrofluoroalkane (HFA-134a) propellant (QVAR The use of tradenames is for product identification purposes only and does not imply endorsement. formulation) in relation to the older corticosteroids. Topical adverse effects such as thrush and dysphonia are rare, but dental erosion is a possibility with powder forms of ICS because of their low pH. Thus, it is important to stress mouth rinsing after administration and maintaining good dental hygiene to minimize this risk. Biochemical adrenal suppression can be readily demonstrated, particularly with high doses of all ICS. The clinical relevance of this was uncertain in the past, but there have now been >50 reported cases of acute adrenal crises in children receiving ICS, most of whom were on fluticasone propionate. In order to minimize the risk of symptomatic adrenal suppression, it is important to back-titrate the ICS dose and alert families of children receiving high-dose ICS of this potential adverse effect. A pediatric endocrine opinion should be sought if adrenal suppression is suspected. The older ICS cause temporary slowing of growth velocity, but the limited data available do not show any significant compromise of final adult height. The effect on growth of fluticasone propionate may not be as great as with the older ICS, but the studies have been short term and only used low doses of fluticasone propionate. There have been case reports of growth suppression in children receiving high doses of fluticasone propionate. The limited studies performed on the effect of ICS on bone mineral density in children did not show any adverse effects, but there may be an increased risk of fractures. Hydrofluoroalkane beclomethasone (QVAR) is essentially the same drug as chlorofluorocarbon beclomethasone, but with double the lung deposition owing to the smaller particle size. Thus, it could be expected that any adverse effects seen with chlorofluorocarbon beclomethasone would be the same with hydrofluoroalkane beclomethasone. However, some of the published data, particularly in adults, suggest that hydrofluoroalkane beclomethasone may be less systemically active than chlorofluorocarbon beclomethasone, even at equipotent doses. As yet, there are no long-term data on mometasone, but initial studies in adults suggest there may be less suppression of the hypothalamic-pituitary-adrenal axis, although further studies are required, particularly in children.ICS will remain a cornerstone in the management of persistent pediatric asthma, provided that the diagnosis of asthma is secure. It is very important to use ICS appropriately and to ensure the lowest possible doses are used to achieve symptom control, thus minimizing the risk of serious adverse effects.

Paediatric asthma management in developing countries.

Asthma is a chronic disease that is increasing in prevalence all over the world. The use of inhaled corticosteroids is the main treatment for asthma control. The use of the Global Initiative for Asthma (GINA) guidelines may improve the quality of asthma treatment. Some of the directions in the GINA guidelines may be difficult to apply in developing countries. An important barrier to adequate treatment for asthma in low income countries is the unavailability of inhaled steroids for the general population. Asthma plans must be implemented in these countries with the participation of health systems, medical associations and the pharmaceutical industry. Adaptation of international guidelines to the local situation must occur to make asthma treatment possible for every asthmatic patient. In this paper, we present a review on this subject showing data on the initiatives that significantly improved asthma management.

Management of acute pediatric asthma.

Pediatric asthma prevalence, morbidity, and severity are increasing. Direct costs associated with providing emergency department and inpatient care account for more than 40% of overall dollars spent for this disease in the United States. Physicians in many health care settings may be required to treat a child in severe respiratory distress caused by acute asthma. This article reviews the pathophysiology, evaluation, and treatment of severe asthma exacerbations, or status asthmaticus.

DM programme improves paediatric asthma management

DM programme improves paediatric asthma management