Pediatric Respiratory Assessment Measure Research Articles

Prevalence of Alpha-1 Antitrypsin Deficiency Alleles in a Lithuanian Cohort of Wheezing Small Children.

Severe inherited alpha-1 antitrypsin deficiency (AATD) is an autosomal genetic condition linked to chronic obstructive pulmonary disease (COPD). The significance of heterozygous, milder deficiency variants (PiSZ, PiMZ, PiMS) is less clear. We studied AATD genotypes in 145 children (up to 72 months old) with assessed wheezing severity using the Pediatric Respiratory Assessment Measure (BCCH PRAM score). A control group of 74 children without airway obstruction was included. AAT concentration and Pi phenotype were determined from dry blood spot samples using nephelometry and real-time PCR; PiS and PiZ alleles were identified by isoelectrofocusing. Among the wheezers, the Pi*S allele incidence was 2.07% (3 cases) and the Pi*Z allele was 6.9% (10 cases). The Pi*Z allele frequency was higher in wheezers compared to controls (44.8% vs. 20.27%) and the general Lithuanian population (44.8% vs. 13.6%) and was similar to adult COPD patients in Lithuania: Pi*S 10.3% vs. 15.8% and Pi*Z 44.8% vs. 46.1%. No association was found between AAT genotypes and wheezing severity. Finding that wheezer children exhibit a frequency of Z* and S* alleles like that found in adults with COPD suggests a potential genetic predisposition that links early wheezing in children to the development of COPD in adulthood. Larger cohort studies are needed to confirm this finding.

Diaphragmatic Ultrasound in Children With Asthma Exacerbations.

Asthma is a leading cause of pediatric emergency department visits, yet few tools exist to objectively measure asthma severity. Diaphragmatic ultrasound (DUS) is a novel method of assessing respiratory distress; however, data are lacking for children.Our primary aim was to determine if diaphragmatic excursion (DE), diaphragmatic thickening (DT), or diaphragmatic thickening fraction (TF) correlated with asthma severity as determined by the Pediatric Respiratory Assessment Measure (PRAM) score. Secondarily, we examined if these parameters correlated with need for respiratory support and evaluated interrater reliability. We conducted a prospective study of children 5-18 years presenting to a pediatric emergency department with an asthma exacerbation. Diaphragmatic ultrasound was performed by a trained pediatric emergency medicine sonologist in subcostal (DE) and midaxillary (DT). Thickening fraction was calculated from DT values as previously described in literature. To evaluate interrater reliability, a subset of subjects had DUS performed by a second sonologist. We enrolled 47 subjects for a total of 51 encounters. The mean age was 9.1 ± 3.7 years. Twenty-five (49%) had mild, 24 (47%) had moderate, and 2 (4%) had severe asthma. There was a significant difference in midaxillary DT and TF between children with mild and moderate asthma ( P = 0.02; mean difference, 0.2 mm; 95% confidence interval [CI], 0.03-0.4 and P = 0.02; mean difference, 0.11 mm; 95% CI, 0.02-0.2, respectively). No difference was found in subcostal DE ( P = 0.43; mean difference, 1.4 mm; 95% CI, -2.1 to 4.8). No association was found between use of positive pressure and DUS parameters. Fourteen encounters had 2 sonologists perform DUS, with strong interrater reliability found for midaxillary DT (Pearson correlation, 0.56) and poor association for subcostal DE (Pearson correlation, 0.18). In this pilot study, we conclude that DUS may be helpful in assessing severity of asthma. The midaxillary view assessment for DT and TF had the best correlation with asthma severity and the best interrater reliability. Future studies may benefit from focusing on the midaxillary view for DT and TF.

Validation of the Spanish version of the Pediatric Asthma Severity Score (PASS) in a population of Hispanic children.

The Pediatric Asthma Severity Score (PASS)is one of the most-used clinical scoring systems for assessing the severity of asthma exacerbations in children. The aim of the present study was to validate a Spanish version of the PASS in a population of Hispanic children with asthma exacerbations living in urban Bogota, Colombia. In a prospective cohort and a validation study, parents/caregivers of children between 2 and 18 years old attended in the emergency department (ED)with asthma exacerbations who were admitted to the inpatient unit were invited to participate in the study. During the hospitalization period, we gathered the necessary data for assessing the criterion validity (comparing its score with the Pediatric Respiratory Assessment Measure [PRAM]), construct validity, interrater reliability, responsiveness, and internal consistency of the Col-PASS,the Colombian version of the PASS. At baseline, the scores of the Col-PASScorrelated positively with the scores of the PRAMscore (ρ = 0.588, p < .001). The baseline Col-PASSscores in patients who required admission to a more complex service were significantly higher than those in patients who presented clinical improvement (1.0 (0.0-2.0) vs. 0.0 (0.0-0.0), p < .001). The interrater reliability was found to be κ = 0.897, 95% CI 0.699-1.000, p < .001. Cronbach's α was .701 for the questionnaire as a whole. The Col-PASShas excellent construct validity, adequate criterion validity, interrater reliability, responsiveness; and acceptable internal consistency when used in children between 2 and 18 years old with asthma exacerbations.

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.

Evaluating the Clinical Impact of a Novel Pediatric Emergency Medicine Curriculum on Asthma Outcomes in Belize.

Respiratory-related complaints prompt most pediatric visits to Karl Heusner Memorial Hospital Authority's (KHMHA) Emergency Department (ED) in Belize. We developed and taught a novel pediatric respiratory emergencies module for generalist practitioners there. We assessed the curriculum's clinical impact on pediatric asthma emergency management. This study assesses the clinical impact of a pediatric emergency medicine curriculum on management of pediatric asthma emergencies at KHMHA in Belize City, Belize. We conducted a randomized chart review of pediatric (aged 2-16 y) visits for asthma-related diagnosis at the KHMHA ED between 2015 and 2018 to assess the training module's clinical impact. Primary outcomes included time to albuterol and steroids. Secondary outcomes included clinical scoring tool (Pediatric Respiratory Assessment Measure [PRAM]) usage, ED length of stay, usage of chest radiography, return visit within 7 days, and hospital admission rates. Kaplan-Meier survival analysis and Cox proportional hazard regression were used. Two hundred eighty-three pediatric asthma-related diagnoses met our inclusion criteria. The patients treated by trained and untrained physician groups were demographically and clinically similar. The time to albuterol was significantly faster in the trained (intervention) group compared with the untrained (control) physician group when evaluating baseline of the group posttraining (P < 0.05). However, the time to steroids did not reach statistical significance posttraining (P = 0.93). The PRAM score utilization significantly increased among both control group and intervention group. The untrained physician group was more likely to use chest radiography or admit patients. The trained physician group had higher return visit rates within 7 days and shorter ED length of stay, but this did not reach statistical significance. The curriculum positively impacted clinical outcomes leading to earlier albuterol administration, increased PRAM score use, obtaining less chest radiographs, and decreased admission rates. The timeliness of systemic steroid administration was unaffected.

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.

Impact of Oral Corticosteroids on Respiratory Outcomes in Acute Preschool Wheeze: A Randomised Clinical Trial

To determine if oral prednisolones given to acutely wheezing preschool-aged children alter respiratory outcomes.A total of 3247 children (aged 24–59 months) with acute wheezing episodes between August 2014 and September 2016 in 3 New Zealand emergency departments (EDs) were potentially eligible. A total of 493 were randomly assigned, and 477 patients were included in the intention-to-treat analysis (238 in the prednisolone group and 239 in the placebo group). Primary outcome data were available on 393 patients (82% overall; 195 (79%) in the prednisolone group and 198 (83%) in the placebo group). Children <24 months of age were purposely excluded, ensuring that those with bronchiolitis were not included.In this double-blind placebo-controlled trial, preschool-aged children with viral-induced wheeze who presented to the ED were randomly assigned to receive 3 days of prednisolone (2 mg/kg) or a placebo. The primary outcome measure was a change in the validated Preschool Respiratory Assessment Measure (PRAM) score 24 hours after the intervention. Secondary outcomes included PRAM score at 4 hours, admission rate, length of ED and inpatient stay, amount of albuterol given in 48 hours, additional treatment with open-label prednisolone, time to return to normal activity, and adverse events, including the need for intravenous (IV) medication, ICU admission, and representation to the ED or primary care provider within 7 days. Pediatric Respiratory Assessment Measure (PRAM) scores (ranging from 0–12) were calculated on the basis of suprasternal retractions, scalene retractions, wheezing, and oxygen saturation in room air. The study was designed as an equivalence trial and powered (power: 95%) to detect the minimal difference in PRAM scores that would disprove the null hypothesis that corticosteroids and placebo are equivalent treatments. In a pilot study (n = 137), researchers determined a SD of 2.3 for change in PRAM score at 24 hours was significant. Therefore, analysis was by intention to treat.Between groups, there was no difference in the primary outcome, the change in PRAM score at 24 hours (difference between means: −0.39; 95% confidence interval [CI]: −0.84 to 0.06, P = .09). The median PRAM score at 24 hours for both groups was 0, with only approximately one-third in either group showing mild disease (PRAM score 1–4) and few with PRAM scores >4 (2.0% and 3.6% in treatment and control groups, respectively). Change in PRAM score at 4 hours was significantly different in the treatment group (−0.67; 95% CI: −1.18 to −0.16; P = .01). No difference in length of ED stay was observed (−0.57; 95% CI: −1.15 to 0.02; P = .06), although admission to the hospital occurred more often in the placebo group (0.67; 95% CI: 0.45 to 1.01; P = .05) as well as additional corticosteroid (0.22; 95% CI: 0.06 to 0.79; P = .01) and IV medication use (0.27; 95% CI: 0.07 to 0.96; P = .03). No difference was observed in representation to the hospital or the primary care provider within 7 days (P = .33 and P = .22, respectively) or ICU admission (undefined P value because only 2 total children went to the ICU) as well as the amount of albuterol given in 48 hours (P = .27).Oral prednisolone does not alter respiratory outcomes at 24 hours or beyond in preschool-aged children presenting with acute wheezing to the ED because most children improved after 24 hours regardless of initial treatment. Subgroup analyses revealed no evidence that the 24-hour treatment effect differed for albuterol responsive children, those with a positive Asthma Predictive Index, or more severe disease at presentation (higher PRAM score). However, those who received prednisolone had less respiratory distress 4 hours after medication administration and a reduced requirement for hospital admission, additional corticosteroid, or IV treatment. These findings suggest that early in-hospital administration of oral prednisolone to preschoolers with wheeze may prevent further deterioration and requirement for escalation of therapy. Additionally, considering the lack of significant difference at 24 hours, oral prednisolone may improve short-term respiratory outcomes for preschoolers presenting with wheeze. However, subsequent doses of oral prednisolone may provide no additional therapeutic benefit.With this robustly designed randomized controlled trial, we are reminded that wheezing preschoolers are a heterogeneous group with numerous factors contributing to a wheezy phenotype. We should consider that they should not be treated the same as older asthmatics, with regards to corticosteroids. With this study, the authors question oral steroid dosing dogma and demonstrate that oral prednisolone may improve short-term respiratory outcomes for wheezing preschoolers but subsequent doses of oral prednisolone may provide no additional therapeutic benefit. Further studies are needed in this population to understand the timing and dosing of corticosteroids.

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.

Hot spots for pediatric asthma emergency department visits in Ottawa, Canada

Objective Pediatric asthma emergency department (ED) visits and repeat visits place a substantial burden on healthcare. National and provincial level studies demonstrate geographic variation in asthma ED visits and links to marginalization, but preclude translation into practical targeting of healthcare delivery. It is important to understand the relationship between pediatric asthma ED visits and marginalization at a more granular level. To map the city-level geographic variation in pediatric asthma ED visit and re-visit rates at the Children’s Hospital of Eastern Ontario (CHEO) in Ottawa, Canada and the relationship with marginalization. Methods We performed a single center retrospective cohort study of children ages 1–17 with one or more ED visits for asthma at the CHEO in Ottawa. Using postal codes, we linked patients to census tracts. Per census tract, we mapped pediatric asthma ED visit and re-visit rates within one year and identified overlap with the Ontario Marginalization Index. Results Of 1,620 children with an index ED visit, 18.5% had a repeat ED visit. We identified 10 hot spot census tracts each for pediatric asthma ED visit and re-visit rates. We identified an overlap between urban hot spots and areas with high ethnic concentration or low dependency. Conclusion At a granular, city-wide level, pediatric asthma ED visit and re-visit rates are heterogeneous. Urban hot spots, in contrast to rural, have more overlap with marginalization, especially ethnic concentration. These methods can be used in other jurisdictions to inform practical community strategies for geographically-targeted prevention of pediatric asthma-related ED visits in vulnerable areas. Abbreviations: ED: Emergency department; CHEO: Children’s Hospital of Eastern Ontario; PRAM: Pediatric Respiratory Assessment Measure; ON-Marg: Ontario Marginalization Index; SES: Socioeconomic status; US: United States Supplemental data for this article can be accessed at publisher’s website.

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 acute asthma scoring systems: a systematic review and survey of UK practice.

BackgroundAcute exacerbations of asthma are common in children. Multiple asthma severity scores exist, but current emergency department (ED) use of severity scores is not known.MethodsA systematic review was undertaken to identify the parameters collected in pediatric asthma severity scores. A survey of Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI) sites was undertaken to ascertain routinely collected asthma data and information about severity scores. Included studies examined severity of asthma exacerbation in children 5–18 years of age with extractable severity parameters.ResultsSixteen articles were eligible, containing 17 asthma severity scores. The severity scores assessed combinations of 15 different parameters (median, 6; range, 2–8). The most common parameters considered were expiratory wheeze (15/17), inspiratory wheeze (13/17), respiratory rate (10/17), and general accessory muscle use (9/17). Fifty‐nine PERUKI centers responded to the questionnaire. Twenty centers (33.1%) currently assess severity, but few use a published score. The most commonly recorded routine data required for severity scores were oxygen saturations (59/59, 100%), heart rate, and respiratory rate (58/59, 98.3% for both). Among well‐validated scores like the Pulmonary Index Score (PIS), Pediatric Asthma Severity Score (PASS), Childhood Asthma Score (CAS), and the Pediatric Respiratory Assessment Measure (PRAM), only 6/59 (10.2%), 3/59 (5.1%), 1/59 (1.7%), and 0 (0%) of units respectively routinely collect the data required to calculate them.ConclusionStandardized published pediatric asthma severity scores are infrequently used. Improved routine data collection focusing on the key parameters common to multiple scores could improve this, facilitating research and audit of pediatric acute asthma.

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.

Vitamin D level in preschool children with recurrent wheezy chest, and its relation to the severity of the wheezing episodes

Background: Recurrent wheezy chest is a common complaint in pediatric practice. Vitamin D is a potent immunomodulator in allergic diseases as wheezy chest and asthma. The prevalence of vitamin D deficiency has been increasing in Egypt leading to significant morbidities. Objectives: This study aimed to assess serum 25 hydroxy (OH) Vitamin D level in preschool children with recurrent wheezy chest, and to assess its relation to the recurrence, severity, and level of control of the wheezing episodes. Methods: The study included 100 preschool children (aged 2 to 5 years), of both sexes, recruited from the Emergency department, Allergy and Pulmonology units at Assiut University Children Hospital, Egypt. They should have at least 3 documented episodes of wheeze, cough, and difficulty breathing in the last year with clinical improvement on inhaled short-acting beta 2 agonists. Patients were subjected to questionnaire-based history, clinical examination, and laboratory investigations (complete blood count (CBC) with the absolute eosinophil count, serum total IgE level, and serum 25 hydroxy (OH) Vitamin D level). Pediatric Respiratory Assessment Measure (PRAM score) for assessment of the severity of the wheezing episodes and Global Initiative for Asthma (GINA) based level of asthma control for children 5 years and younger were applied. The patients were grouped according to PRAM score to mild, moderate and severe episodes and according to vitamin D level as sufficient and below-sufficient groups (including deficient and insufficient patients). Results: 25(OH) Vitamin D level was below-sufficient in 53% of the studied patients (deficient in 32% and insufficient in 21%). PRAM score was significantly lower in patients with sufficient 25(OH) Vitamin D level versus those with below-sufficient level (p < 0.025). There was a significant negative correlation between PRAM score and 25 (OH) Vitamin D level (r = -0.334, p = 0.001). Conclusion: There is an inverse relationship between 25(OH)vitamin D level and parameters of asthma severity, as well as with the level of asthma control in preschool children with recurrent wheezy chest. Keywords: Vitamin D, recurrent wheezy chest, preschool children