Pediatric Respiratory Assessment Measure Score Research Articles

Use of lung ultrasound in school-aged children with wheezing.

There is limited information available on fast and safe bedside tools that could help clinicians establish whether the pathological process underlying cases of wheezing is due to asthmatic exacerbation, asthmatic bronchitis, or pneumonia. The study's aim was to characterize Lung Ultrasound (LUS) in school-aged children with wheezing and evaluate its use for their follow-up treatment. We carried out a cross-sectional study involving 68 consecutive outpatients (mean age 9.9 years) with wheezing and suggestive signs of an acute respiratory infection. An expert sonographer, blinded to all subject characteristics, clinical course, and the study pediatrician's diagnosis, performed an LUS after spirometry and before BDT. The severity of acute respiratory symptoms was determined using the Pediatric Respiratory Assessment Measure (PRAM) score. The LUS was positive in 38.2% (26/68) of patients [12 (46.1%) with multiple B-lines, 24 (92.3%) with consolidation, and 22 (84.6%) with pleural abnormalities]. In patients with pneumonia, asthmatic bronchitis, and asthma, the percentages of those patients with a positive LUS were 100%, 57.7%, and 0%, respectively. Of note, patients with a positive LUS were associated with an increased need for hospital admission (30.8% vs. 2.4%, p = 0.001), administration of oxygen therapy (14.6% vs. 0%, p = 0.009), oral corticosteroids (84.6% vs. 19.0%, p < 0.001), and antibiotics (88.5% vs. 11.9%, p < 0.001); and a higher median value of PRAM score (4.0 (2.0-7.0) vs. 2.0 (1.0-5.0); p < 0.001). Our findings would suggest the use of LUS as a safe and cheap tool used by clinicians to define the diagnosis of school-aged children with wheezing of unknown causes.

Assessment and management of asthma exacerbations in an emergency department unit.

The Pediatric Respiratory Assessment Measure (PRAM) score is a useful tool for the assessment of asthma exacerbations in children. This study aimed to estimate the risk of hospitalization in children, assessed with the PRAM score and having mild-moderate asthma exacerbation, who were treated with salbutamol delivered via a metered-dose inhaler and spacer (MDI/S). The study population consisted of children aged 3-16 years with mild-moderate asthma exacerbations. All children received 1mg/kg prednisolone p.o. (max 40 mg) and 4-6 puffs of salbutamol via MDI/S. Fifty patients participated in the study. Admission was associated positively with the initial PRAM score (OR: 18.91, CI: 2.42-123.12, P = 0.005) and negatively with the improvement in PRAM score (OR: 0.52, CI: 0.01-0.78, P = 0.032). PRAM is a reliable tool that can be used effectively to estimate the asthma exacerbation severity.

COMPARATIVE ANALYSIS ON NON-VENTILATORY MANAGEMENTS IN ACUTE ASTHMA

Introduction: Acute asthma attacks or acute asthma can be defined as episodes of progressive increase in shortness of breath, cough, wheezing, chest tightness, or some combination of these symptoms. It includes the aggravation, inflammation, and obstruction of the bronchial tubes, which permit air all through the lungs. Most exacerbations are overseen in the outpatient setting. In the United States in 2004 there were 14.7 million visits to doctor workplaces and clinic outpatient divisions for acute asthma. In pediatric patients, a scoring rubric called the Pediatric Respiratory Assessment Measure (PRAM) has been created to evaluate a patient's acute asthma seriousness utilizing a mix of scalene muscle compression, suprasternal withdrawals, wheezing, air entry, and oxygen saturation. noninvasive ventilation has a few possible upper hands over intubation and intrusive mechanical ventilation: there are fewer requirements for sedation, the patient is allowed to talk, ventilation can be briefly suspended to permit the patient to take tastes of liquid or to cough and expectorate, and there is a lower hazard of ventilator-related pneumonia&#x0D; Aims and Objectives: The study intended to compared the efficiency of using oxygen inhalation and rapid-acting bronchodilator as first line management of acute exacerbant asthma.&#x0D; Materials and Methods: The study design is retrospective cross-sectional which was conducted during the period of 7 Months The study has considered 100 patients, among which 45 patients are male and 55 patients are female. The patients who visited the Emergency Department were considered. The patients on arrival to the emergency department was assessed for PRAM score (Initial PRAM score) and was interpreted. Then either oxygen or Short-Acting Beta Agonist (Salbutamol) inhalation was given. Then again, after a fixed interval, the patient’s PRAM score was assessed (Post-Interventional PRAM score). PRAM score was assessed and interpreted.&#x0D; Result: The study found that, after intervention, Group 1 achieved PRAM score of 4.48±1.41 in Group 1 (Oxygen group) while Group 2 (Short-Acting Beta Agonist inhalation) achieved 6.12±1.47. It was found that in patients of Group 1, the mean of changes in all the patients was 6 while in the patients of Group 2 was 4.18.&#x0D; Conclusion: The study concludes that the acute asthmatic episode in emergency department can be managed by oxygen inhalation better than Short-Acting Beta Agonist inhalation. Oxygen inhalation is easier to give as compared to intubation and is also efficient in lowering PRAM score and hence, evidently showed the efficacy for proper management of severe acute asthma in emergency setting.&#x0D; Keywords: pram, acute asthma, oxygen, salbutamol, non-ventilatory

Comparative effectiveness of oral dexamethasone vs. oral prednisolone for acute exacerbation of asthma: A randomized control trial.

Background:Acute exacerbation of asthma is a common condition leading to emergency visits. Prednisolone is a commonly prescribed drug in the standard management of acute exacerbation of asthma along with other drugs. This study was planned to see the efficacy of oral dexamethasone when compared with oral prednisolone in the management of acute exacerbation of asthma.Methods:A single-center pilot study in the form of randomized control trial was done by recruiting children aged 2–14 years diagnosed with acute asthma exacerbation with mild to moderate severity. A total of 88 patients received oral dexamethasone (0.3 mg/kg) in two doses 24 h apart, which was compared with 87 patients who received oral prednisolone (1 mg/kg) in two divided doses 12 h apart for 5 days. The patients were assessed at the time of admission (zero hour), at 4th hour, and on the 5th day by various parameters such as respiratory rate, use of accessory muscles, Pediatric Respiratory Assessment Measure (PRAM) score, peak expiratory flow rate (PEFR), 6-h admission stay, and rate of hospital admission.Results:Baseline demographic profile, clinical characteristics, comorbidities, indoor pollution, and use of Metered Dose Inhaler (MDI) among the two study groups were comparable. Six-hour emergency stay and rate of admission were significantly lower in the dexamethasone group (P < 0.05). Improvement in PRAM score, PEFR, use of accessory muscles, and respiratory rate was also better in dexamethasone group at the 4th hour and 5th day (P < 0.05). In addition, oral dexamethasone was shown to have less incidence of vomiting/gastritis than prednisolone (P < 0.05).Conclusion:Oral dexamethasone can be considered a reliable and better option as compared with prednisolone due to its faster action and minimal side effects.

To determine the association between asthma severity and hospital admission measured by Pediatric Respiratory Assessment Measure (PRAM) score at Indus Hospital and Health Network, Karachi, Pakistan, 2020-2021.

Objectives:To determine the association between asthma severity and the likelihood of hospitalization by using Pediatric Respiratory Assessment Measure (PRAM) score for pediatric patients who present to the emergency department (ED) with mild, moderate or severe asthma exacerbations and those who received standard intensive asthma therapy.Methods:This was a retrospective study conducted in children aged between 2 to 14 years. The data was entered and analysed using Statistical Package for the Social Sciences (SPSS) version 21. To be included in the study, the children must have received “intensive asthma therapy” defined as administration of systemic corticosteroids with three albuterol treatments and ipratropium.Results:A total of 437 patients were enrolled in the study out of which 250 were male and 187 were female. The mean age was 6.1 ± 3.4 years with a minimum age of two and a maximum age of 14 years. The 4-hour PRAM score (AUC = 0.88) overall significantly improved the predictive value of admission (p value <0.001) as compared to the PRAM score calculated at triage (AUC = 0.81).Conclusion:The 4-hour PRAM score is the best predictor for the need of hospitalization. It is suggested that these results are applied clinically in the pediatric ED to improve patient flow and to better facilitate intensive therapy of patients at triage to decrease the need for hospitalization.

Association Between Intravenous Magnesium Therapy in the Emergency Department and Subsequent Hospitalization Among Pediatric Patients With Refractory Acute Asthma

Despite guidelines recommending administration of intravenous (IV) magnesium sulfate for refractory pediatric asthma, the number of asthma-related hospitalizations has remained stable, and IV magnesium therapy is independently associated with hospitalization. To examine the association between IV magnesium therapy administered in the emergency department (ED) and subsequent hospitalization among pediatric patients with refractory acute asthma after adjustment for patient-level variables. This post hoc secondary analysis of a double-blind randomized clinical trial of children with acute asthma treated from September 26, 2011, to November 19, 2019, at 7 Canadian tertiary care pediatric EDs was conducted between September and November 2020. In the randomized clinical trial, 816 otherwise healthy children aged 2 to 17 years with Pediatric Respiratory Assessment Measure (PRAM) scores of 5 points or higher after initial therapy with systemic corticosteroids and inhaled albuterol with ipratropium bromide were randomly assigned to 3 nebulized treatments of albuterol plus either magnesium sulfate or 5.5% saline placebo. Intravenous magnesium sulfate therapy (40-75 mg/kg). The association between IV magnesium therapy in the ED and subsequent hospitalization for asthma was assessed using multivariable logistic regression analysis. Analyses were adjusted for year epoch at enrollment, receipt of IV magnesium, PRAM score after initial therapy and at ED disposition, age, sex, duration of respiratory distress, previous intensive care unit admission for asthma, hospitalizations for asthma within the past year, atopy, and receipt of oral corticosteroids within 48 hours before arrival in the ED, nebulized magnesium, and additional albuterol after inhaled magnesium or placebo, with site as a random effect. Among the 816 participants, the median age was 5 years (interquartile range, 3-7 years), 517 (63.4%) were boys, and 364 (44.6%) were hospitalized. A total of 215 children (26.3%) received IV magnesium, and 190 (88.4%) of these children were hospitalized compared with 174 of 601 children (29.0%) who did not receive IV magnesium. Multivariable factors associated with hospitalization were IV magnesium receipt from 2011 to 2016 (odds ratio [OR], 22.67; 95% CI, 6.26-82.06; P < .001) and from 2017 to 2019 (OR, 4.19; 95% CI, 1.99-8.86; P < .001), use of additional albuterol (OR, 5.94; 95% CI, 3.52-10.01; P < .001), and increase in PRAM score at disposition (per 1-U increase: OR, 2.24; 95% CI, 1.89-2.65; P < .001). In children with a disposition PRAM score of 3 or lower, receipt of IV magnesium therapy was associated with hospitalization (OR, 8.52; 95% CI, 2.96-24.41; P < .001). After adjustment for patient-level characteristics, receipt of IV magnesium therapy after initial asthma treatment in the ED was associated with subsequent hospitalization. This association also existed among children with mild asthma at ED disposition. Evidence of a benefit of IV magnesium regarding hospitalization may clarify its use in the treatment of refractory pediatric asthma. ClinicalTrials.gov: NCT01429415.

Pediatric respiratory assessment measure in evaluation of the severity of bronchial asthma exacerbation in children

Objective The aim was to study the role of pediatric respiratory assessment measure (PRAM) score in evaluation of acute asthma exacerbation in children. Background Acute severe asthma is one of the most common medical emergency situations in childhood, where accurate assessment and management is of extreme importance and may be lifesaving. PRAM score has been used to classify asthma severity and treatment. Patients and methods A prospective cohort study was adopted by applying the PRAM score on 108 asthmatic children presented to the Emergency Department of Elraml Pediatric Hospital in Alexandria by acute asthma exacerbation in the period of the study. Results The study included 66 (61.1%) boys and 42 (38.9%) girls, aged from 2 to 12 years, with mean age of 5.07 ± 2.68 years. The most common triggering factor according to our study was viral infection or common cold (90.7%). Increasing severity of acute asthma exacerbation was associated with increasing initial PRAM score. There was significantly increased severity of grade of PRAM score after initial bronchodilator therapy in relation to young aged children ( Conclusion PRAM score in this study is useful for predicting fate of patients in emergency room, and after initial bronchodilator therapy, it is an excellent sensitive and specific tool to predict the admitted patients from the discharged patients.

High flow nasal cannula in asthmatic children with suspected COVID-19

Abstract Introduction: The use of a high-flow nasal cannula as an alternative treatment for acute respiratory failure can reduce the need for invasive mechanical ventilation and the duration of hospital stays. Objective: The present study aimed to describe the use of a high-flow nasal cannula in pediatric asthmatic patients with acute respiratory failure and suspected COVID-19. Methods: To carry out this research, data were collected from medical records, including three patients with asthma diagnoses. The variables studied were: personal data (name, age in months, sex, weight, and color), clinical data (physical examination, PRAM score, respiratory rate, heart rate, and peripheral oxygen saturation), diagnosis, history of the current disease, chest, and laboratory radiography (arterial blood gases and reverse-transcriptase polymerase chain reaction). Clinical data were compared before and after using a high-flow nasal cannula. Results: After the application of the therapy, a gradual improvement in heart, respiratory rate, PaO2/FiO2 ratio, and the Pediatric Respiratory Assessment Measure score was observed. Conclusion: The simple and quick use of a high-flow nasal cannula in pediatric patients with asthma can be safe and efficient in improving their respiratory condition and reducing the need for intubation.

Validation of the Hospital Asthma Severity Score (HASS) in children ages 2–18 years old

Introduction The Hospital Asthma Severity Score (HASS) was developed to communicate inpatient asthma severity between providers. The purpose of this prospective study was to validate the HASS against the Pediatric Respiratory Assessment Measure (PRAM) and spirometry for assessment of inpatient asthma exacerbation severity in patients 2–18 years old, at a single point-in-time. Methods This study was registered with clinicaltrials.gov (NCT02782065). Children admitted to a tertiary care, free-standing children’s hospital were assessed for asthma severity using the HASS, PRAM, and pulmonary function by spirometry. Inter-rater agreement of HASS and PRAM scores was assessed between two blinded clinician raters. Spirometry results were obtained by a certified pulmonary laboratory technician and correlated with HASS and PRAM scores. Results The sample included 58 subjects. Allowing for a one-point difference in continuous HASS and PRAM scores, inter-rater agreement was 79% for the HASS and 60% for the PRAM. When the scores were categorized as mild, moderate, and severe, inter-rater agreement was 62% for the HASS and 93% for the PRAM (p < .0001). Additionally, intra-rater agreement between HASS and PRAM severity categories was 71% for Rater 1 and 64% for Rater 2. A weak correlation was noted between both the HASS and FEV1 (r = –0.31; p = 0.11), and PRAM and FEV1 (r = –0.30; p = 0.11) for the 29 subjects with acceptable spirometry results. Conclusions The HASS and PRAM have acceptable inter-rater and intra-rater agreement. These results support validation of the HASS for managing hospitalized patients during asthma exacerbations.

Effect of Nebulized Magnesium vs Placebo Added to Albuterol on Hospitalization Among Children With Refractory Acute Asthma Treated in the Emergency Department

While intravenous magnesium decreases hospitalizations in refractory pediatric acute asthma, it is variably used because of invasiveness and safety concerns. The benefit of nebulized magnesium to prevent hospitalization is unknown. To evaluate the effectiveness of nebulized magnesium in children with acute asthma remaining in moderate or severe respiratory distress after initial therapy. A randomized double-blind parallel-group clinical trial from September 26, 2011, to November 19, 2019, in 7 tertiary-care pediatric emergency departments in Canada. The participants were otherwise healthy children aged 2 to 17 years with moderate to severe asthma defined by a Pediatric Respiratory Assessment Measure (PRAM) score of 5 or greater (on a 12-point scale) after a 1-hour treatment with an oral corticosteroid and 3 inhaled albuterol and ipratropium treatments. Of 5846 screened patients, 4332 were excluded for criteria, 273 declined participation, 423 otherwise excluded, 818 randomized, and 816 analyzed. Participants were randomized to 3 nebulized albuterol treatments with either magnesium sulfate (n = 410) or 5.5% saline placebo (n = 408). The primary outcome was hospitalization for asthma within 24 hours. Secondary outcomes included PRAM score; respiratory rate; oxygen saturation at 60, 120, 180, and 240 minutes; blood pressure at 20, 40, 60, 120, 180, and 240 minutes; and albuterol treatments within 240 minutes. Among 818 randomized patients (median age, 5 years; 63% males), 816 completed the trial (409 received magnesium; 407, placebo). A total of 178 of the 409 children who received magnesium (43.5%) were hospitalized vs 194 of the 407 who received placebo (47.7%) (difference, -4.2%; absolute risk difference 95% [exact] CI, -11% to 2.8%]; P = .26). There were no significant between-group differences in changes from baseline to 240 minutes in PRAM score (difference of changes, 0.14 points [95% CI, -0.23 to 0.50]; P = .46); respiratory rate (0.17 breaths/min [95% CI, -1.32 to 1.67]; P = .82); oxygen saturation (-0.04% [95% CI, -0.53% to 0.46%]; P = .88); systolic blood pressure (0.78 mm Hg [95% CI, -1.48 to 3.03]; P = .50); or mean number of additional albuterol treatments (magnesium: 1.49, placebo: 1.59; risk ratio, 0.94 [95% CI, 0.79 to 1.11]; P = .47). Nausea/vomiting or sore throat/nose occurred in 17 of the 409 children who received magnesium (4%) and 5 of the 407 who received placebo (1%). Among children with refractory acute asthma in the emergency department, nebulized magnesium with albuterol, compared with placebo with albuterol, did not significantly decrease the hospitalization rate for asthma within 24 hours. The findings do not support use of nebulized magnesium with albuterol among children with refractory acute asthma. ClinicalTrials.gov Identifier: NCT01429415.

A 3-day course of 1 mg/kg versus 2 mg/kg bodyweight prednisolone for 1- to 5-year-old children with acute moderate exacerbation of asthma: a randomized double-blind noninferiority trial

Even though the guidelines on the management of preschool asthma recommend early use of corticosteroids for acute moderate-to-severe exacerbations, considerable variation exists with regard to type and dose of steroids. To compare the clinical outcomes and side effect profile between 1 mg/kg/day and 2 mg/kg/day of oral prednisolone when administered for 3 days in preschool children with acute moderate asthma exacerbations. Randomized double-blind noninferiority trial was done in the paediatric emergency of a teaching hospital. A total of 128 children aged 1 to 5 years who presented to the paediatric emergency with acute moderate exacerbation of asthma were enrolled. They were randomized into two groups. One group received 1 mg/kg/day and the other 2 mg/kg/day of oral prednisolone for 3 days. Severity of asthma exacerbation was measured by Pediatric Respiratory Assessment Measure (PRAM) score. The PRAM scores, wheeze recurrence, and side effect profile were compared and analyzed between the two groups. The difference in the PRAM scores at 1, 2, 3, and 4 hours after intervention between the two groups was statistically insignificant. Need for escalation of therapy, salbutamol nebulization, time for resolution of symptoms, and recurrence of wheeze were similar between the two groups. Vomiting was significantly less frequent in low-dose group with a relative risk of 0.19 to 0.99 compared to high-dose prednisolone. Prednisolone at a dose of 1 mg/kg/day was not inferior to 2 mg/kg/day in terms of clinical improvement and recurrence of wheeze within 1 week and has less frequent vomiting compared to higher dose.

Pediatric respiratory assessment measure score in assessing the severity of acute asthma in children

Background: Asthma is a chronic inflammatory disease of the lung airways resulting in episodic airflow obstruction. Management of acute pediatric asthma depends on assessment of asthma severity which is difficult in children due to poor coordination. This study is to evaluate the usefulness of a simple yet effective alternative like Pediatric respiratory assessment measure (PRAM) score in assessing the severity and outcome of an acute exacerbation of wheeze in children and to identify the PRAM score predicting the need for hospitalization.Methods: A prospective cohort study was done on 127 children for a period of 2 months in 2018, admitted with acute exacerbation of wheeze using PRAM scores at admission and following each treatment modalities. Usefulness of score in assessing severity was evaluated.Results: Increasing severity was associated with increasing initial PRAM score. Initial mean PRAM score of 11 in severe persistent forms, 7 in moderate persistent, 6.73 in mild persistent and 5.37 in mild intermittent was found. 59.1% of patients had a positive family history. The most common trigger factor according to our study was viral upper respiratory tract infection (50.4%) followed by exposure to dust (13.4%). Patients who were admitted to the Pediatric Intensive Care Unit (PICU) had the maximum number of interventions.Conclusions: In our study, statistically it was proved that PRAM Score is a tool that can be used across different ages and PRAM Score is a tool that can be used to assess severity of asthma.

Challenges in assessing the efficacy of systemic corticosteroids for severe wheezing episodes in preschool children

Summary This letter addresses the controversial issue of the use of oral corticosteroids during wheezing exacerbations in preschool-aged children by demonstrating findings of a prematurely terminated multi-center clinical trial, discussing lessons learned, and suggesting future directions.

Use of a standardized asthma severity score to determine emergency department disposition for paediatric asthma: A cohort study.

We recently introduced a clinical practice pathway for the management of asthma that uses the Pediatric Respiratory Assessment Measure (PRAM) to guide emergency department (ED) treatment and disposition. The pathway recommends discharge for patients who achieve improvement to PRAM <4 at 1 hour after the last bronchodilator. We evaluated practice variation and patient outcomes associated with PRAM-directed disposition recommendations. We conducted a retrospective cohort study of children aged 2 to 17 years treated for moderate asthma (PRAM score 4-7) using our asthma clinical pathway. We measured 1) the proportion of children discharged per pathway criteria who returned to our ED within 24 hours and 2) the proportion of children observed beyond the pathway discharge criteria who deteriorated (PRAM ≥4). We analyzed 385 patient records from September 2013 to February 2015. Among 145 (37.7%) patients discharged per pathway criteria, 4 (4/145; 2.8%) returned within 24 hours. The remaining 240 (62.2%) were observed beyond the pathway discharge criteria; 76/240 (31.7%) had a subsequent deterioration (PRAM score ≥ 4) and 25/240 (10.4%) were hospitalized. Of those who deteriorated, 46/76 (60.5%) worsened within the first additional hour of observation. We observed significant deviation from our PRAM-directed pathway discharge criteria and that a significant proportion of observed patients experienced clinical deterioration beyond the first hour of observation. We recommend observing children with moderate asthma for 2 or 3 hours from last bronchodilator therapy if PRAM < 4 is maintained, to capture the majority (97.7% or 99.7%) of patients who require further intervention and hospitalization.

LA phonospirometry technique compared to pediatric respiratory assessment measure and peak expiratory flow measurement as a novel technique to assess the severity of an asthma exacerbation

Objective: Asthma is a common chronic disease treated in emergency departments. The measurements of Peak Expiratory Flow (PEF) and Pediatric Respiratory Assessment Measure (PRAM) scores have been recommended as objective techniques in the assessment of acute asthma exacerbations, but have multiple barriers limiting their use. The Los Angeles phonospirometry technique is an easier, trans-cultural technique. The technique assesses dyspnea by measuring how many seconds a child is able to chant “LA LA LA” in a single breath. The objective of this study is to determine the correlation of this technique with PEF measurements and PRAM scores in children with acute asthma exacerbations, both before and after nebulized bronchodilator treatment. Methods: A convenient sample of children aged 5–17 years being treated for asthma in the ED was enrolled. Phonospirometry, PRAM, and PEF measurements were obtained through pre and post inhaled bronchodilator treatments. The highest values from each measurement were correlated using Spearman's correlation coefficient. Results: A total of 91 children were enrolled. The correlations at pre-treatment, after first, second, and third treatments between phonospirometry and PEF were 0.38 (p < 0.001), 0.60 (p < 0.001), 0.54 (p < 0.001), 0.52 (p < 0.01), respectively; between phonospirometry and PRAM were −0.37 (p < 0.001), −0.42 (p < 0.001), −0.26 (p < 0.05), and −0.06 (p > 0.05), respectively; and between PEF and PRAM were −0.6 (p < 0.01), −0.54 (p < 0.001), −0.38 (p < 0.01), and −0.36 (p − 0.05), respectively. Conclusions: This novel technique correlates mild to moderately with PEF, and shows promising aide in the assessment of children with acute asthma exacerbations.

Comparison between pediatric respiratory assessment measure (PRAM) score and Wood's asthma score to assess acute asthma exacerbation.

Wood's score, the assessment of childhood respiratory failure, has been used to assess childhood acute asthma severity in Thailand since 19th century. However, PRAM score, which is increasingly used in Western countries has not been evaluated among Thai children with asthma. This study aims to determine whether Wood or PRAM score is better prediction of severity of childhood asthma exacerbation. The prospective comparative study of severity asthma score was performed in asthmatic children, 2-18 years old, with acute asthma exacerbation at Queen Sirikit National Institute of Child Health. PRAM and Wood's score were separately determined by 2 physicians. The patients were further assessed at 0, 4 or 24 hours after their admissions. The asthma treatment followed GINA guideline. There were 80 asthmatic patients, mean aged 5.71 ± 2.95 years. The admission rate was 28.8% with the mean length of stay = 4 ± 1 days. PRAM was correlated with Wood's score (Spearman's correlation p = 0.900, p < 0.001 at triage, and = p0.981, p < 0.001). The highlight of this study is the finding that intraclass correlation of PRAM is better than Wood asthma score (ICC = 0.944; 95%CI 0.913-0.964, 0.898; 95%CI 0.841-0.935, respectively). ROC indicated Wood's score ≤ 4 and PRAM ≤ 5, in the requirement for admission. PRAM and Wood's score are both promising in prediction of severity and outcome of childhood asthma exacerbation.

Zinc Supplementation in Children with Asthma Exacerbation.

Zinc deficiency has demonstrated an association with the risk of asthma. This study aimed to evaluate the efficacy of zinc supplementation in reducing the severity of childhood asthma exacerbation. A number of 42 children with asthma exacerbation admitted to the hospital were randomized to receive either zinc bis-glycinate (30 mg elemental zinc/day) or a placebo in adjuvant to the standard treatment. The pediatric respiratory assessment measure (PRAM) was used to measure the asthma severity. The primary outcome was a change in asthma severity from the baseline to the end of study. The study found that PRAM score in the zinc group showed a more rapid decrease compared to the control group at the 24-hour (2.2±1.3 vs. 1.2±1.3; P = 0.015) and 48-hour (3.4±2.0 vs. 2.2±1.8; P = 0.042) intervals. At admission, overall mean serum zinc level was 63.8 mg/dL and 57.1% of children had zinc deficiency with no difference in prevalence between groups. PRAM scores did not differ between children with low and normal zinc status. In conclusion, zinc supplementation as the adjuvant therapy to the standard treatment during asthma exacerbation resulted in rapid lessening of severity.

Ketamine versus aminophylline for acute asthma in children: A randomized, controlled trial.

BACKGROUND:There is a lack of consensus regarding second-line therapy in children with acute asthma who fail to the standard therapy. Ketamine had bronchodilator property and may be useful in the treatment of acute asthma.OBJECTIVE:The objective of this study was to evaluate the efficacy and safety of ketamine as compared to aminophylline in children with acute asthma who respond poorly to the standard therapy.METHODS:This randomized controlled trial included patients with acute asthma having Pediatric Respiratory Assessment Measure (PRAM) score ≥5 at 2 h of standard therapy. The enrolled patients received either intravenous (IV) ketamine or IV aminophylline. Primary outcome measure was change in PRAM score at the end of intervention. Secondary outcome measures included adverse effects, change in PO2and PCO2, need for mechanical ventilation, and duration of hospital stay.RESULTS:The trial included 24 patients each in ketamine and aminophylline groups. The baseline parameters were similar between the groups. The primary outcome was similar in both the groups with a change in PRAM score of 4.00 ± 1.25 and 4.17 ± 1.68 (P = 0.699) in ketamine and aminophylline groups, respectively. The secondary outcomes were not different between the groups.CONCLUSION:Ketamine and aminophylline were equally effective for children with acute asthma who responded poorly to the standard therapy.

A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department

In acute exacerbations of asthma in children, corticosteroids reduce relapses, subsequent hospital admission, and the need for ß2-agonist bronchodilators. Prednisolone is the most commonly used corticosteroid, but prolonged treatment course, vomiting, and a bitter taste may reduce patient compliance. Dexamethasone has a longer half-life and has been used safely in other acute pediatric conditions. We examine whether a single dose of oral dexamethasone is noninferior to prednisolone in the emergency department (ED) treatment of asthma exacerbations in children, as measured by the Pediatric Respiratory Assessment Measure (PRAM) at day4. We conducted a randomized, open-label, noninferiority trial comparing oral dexamethasone (single dose of 0.3 mg/kg) with prednisolone (1 mg/kg per day for 3 days) in patients aged 2 to 16 years and with a known diagnosis of asthma or at least 1 previous episode of ß2-agonist-responsive wheeze who presented to a tertiary pediatric ED. The primary outcome measure was the mean PRAM score (range of 0 to 12 points) performed on day 4. Secondary outcome measures included requirement for further steroids, vomiting of study medication, hospital admission, and unscheduled return visits to a health care practitioner within 14 days. There were 245 enrollments involving 226 patients. There was no difference in mean PRAM scores at day 4 between the dexamethasone and prednisolone groups (0.91 versus 0.91; absolute difference 0.005; 95% CI -0.35 to 0.34). Fourteen patients vomited at least 1 dose of prednisolone compared with no patients in the dexamethasone group. Sixteen children (13.1%) in the dexamethasone group received further systemic steroids within 14 days after trial enrollment compared with 5 (4.2%) in the prednisolone group (absolute difference 8.9%; 95% CI 1.9% to 16.0%). There was no significant difference between the groups in hospital admission rates or the number of unscheduled return visits to a health care practitioner. In children with acute exacerbations of asthma, a single dose of oral dexamethasone (0.3 mg/kg) is noninferior to a 3-day course of oral prednisolone (1 mg/kg per day) as measured by the mean PRAM score on day4.

Noninvasive Bedside Assessment of Acute Asthma Severity Using Single-Breath Counting

The single-breath counting (SBC) method for assessment of asthma exacerbation severity has been evaluated in adults during exacerbations and in pediatric patients during routine settings. Single-breath counting has not been evaluated in children during exacerbations. We sought to assess criterion validity and responsiveness of SBC with percent-predicted FEV1 (%FEV1) and the Pediatric Respiratory Assessment Measure (PRAM), a validated acute asthma severity score. We prospectively enrolled subjects aged 7 to 17 years with acute asthma exacerbations. Single-breath counting, %FEV1, and PRAM were obtained before treatment and 2 hours after initiating therapy. Multivariable linear regression models were used to examine associations of pretreatment SBC with %FEV1 and PRAM (criterion validity) and 2-hour change of these measures (responsiveness). With a 2-sided α of 0.05, SBC SD of 8.5, and 90% power to detect an adjusted R of greater than 0.36 for SBC with each outcome measure, a minimum sample of 20 participants was necessary. From June to November 2011, 51 participants were enrolled, with median (interquartile range) age of 8.46 years (6.92-11.4 years); male sex, n = 40 (78%); and African American race, n = 33 (64%). Before treatment, 42 (92%) were able to successfully perform SBC, and 24 (51%) %FEV1. Median pretreatment SBC obtained was 16 (10-24); %FEV1, 50 (26-71); and PRAM, 5 (1-5). Single-breath counting demonstrates modest criterion validity for predicting the pretreatment PRAM score and a trend for predicting %FEV1. Single-breath counting does not appear to be responsive to change of these measures in response to treatment and has limited validity as a measure of acute asthma severity.