Pediatric Respiratory Assessment Measure Research Articles

Single dose oral dexamethasone versus multi-dose prednisolone in the treatment of acute exacerbations of asthma in children who attend the emergency department: study protocol for a randomized controlled trial

BackgroundAsthma is a major cause of pediatric morbidity and mortality. In acute exacerbations of asthma, corticosteroids reduce relapses, subsequent hospital admission and the need for ß2-agonist therapy. Prednisolone is relatively short-acting with a half-life of 12 to 36 hours, thereby requiring daily dosing. Prolonged treatment course, vomiting and a bitter taste may reduce patient compliance with prednisolone. Dexamethasone is a long-acting corticosteroid with a half-life of 36 to 72 hours. It is used frequently in children with croup and bacterial meningitis, and is well absorbed orally. The purpose of this trial is to examine whether a single dose of oral dexamethasone (0.3 mg/kg) is clinically non-inferior to prednisolone (1 mg/kg/day for three days) in the treatment of exacerbations of asthma in children who attend the Emergency Department.Methods/designThis is a randomized, non-inferiority, open-label clinical trial. After informed consent with or without assent, patients will be randomized to either oral dexamethasone 0.3 mg/kg stat or prednisolone 1 mg/kg/day for three days. The primary outcome measure is the comparison between the Pediatric Respiratory Assessment Measure (PRAM) across both groups on Day 4. The PRAM score, a validated, responsive and reliable tool to determine asthma severity in children aged 2 to 16 years, will be performed by a clinician blinded to treatment allocation. Secondary outcomes include relapse, hospital admission and requirement for further steroid therapy. Data will be analyzed on an intention-to-treat and a per protocol basis. With a sample size of 232 subjects (105 in each group with an estimated 10% loss to follow-up), we will be able to reject the null hypothesis - that the population means of the experimental and control groups are equal with a probability (power) of 0.9. The Type I error probability associated with this test (of the null hypothesis) is 0.05.DiscussionThis clinical trial may provide evidence that a shorter steroid course using dexamethasone can be used in the treatment of acute pediatric asthma, thus eliminating the issue of compliance to treatment.RegistrationISRCTN26944158 and EudraCT Number 2010-022001-18

Performance of the Acute Asthma Intensity Research Score (AAIRS) for acute asthma research protocols

There are limited validated severity measures for acute asthma exacerbations that can be measured in all subjects regardless of age or ability to cooperate and that are sufficiently comprehensive and sensitive to be used as an outcome measure for research protocols. The 13-point (0 – 12) Pediatric Respiratory Assessment Measure (PRAM) was developed in young children with exacerbations using airway resistance as the reference measure and discriminated baseline severity and responsiveness after treatment.1 We have reported that the RAD score, a simple bedside severity score for pediatric patients with acute asthma exacerbations, performs as well as the PRAM score.2 The PRAM includes scalene retractions (Table), a sign that the PRAM developers noted in only 2% of their participants before treatment. Although the PRAM developers note that a training lecture and demonstration were used for score assessors, to our knowledge this teaching tool has not been reported.1 In addition, it has long been recognized that scalene retractions may be consistently ascertained only by palpation or electromyography and that this assessment may be difficult.3 In a prospective research protocol of pediatric patients with acute asthma exacerbations, we experienced the same difficulty in being able to visually discern scalene muscle retractions. Because of this, we studied the substitution of scalene muscle retractions with visual intercostal and subcostal retractions and expiratory phase prolongation. Table PRAM and AAIRS acute asthma severity score components, values assigned by severity of each component, and ranges of component values comprising each score This modification also allows for an acute asthma severity score with a greater number of relevant components that have been used in previous scores, are easy to observe, and might more fully capture the variability of exacerbation severity needed for research protocols.4 These modifications resulted in a 17-point (0 – 16) Acute Asthma Intensity Research Score (AAIRS) that excludes scalene and includes intercostal and subcostal retractions, as well as expiratory phase prolongation. Our objectives were to assess discrimination of baseline severity and responsiveness of the PRAM and AAIRS and the distributions of score values in children with exacerbations.5–7 To assess score discrimination and responsiveness, we studied a prospective cohort aged 5–17 years presenting to a tertiary, academic pediatric emergency department with acute asthma exacerbations. AAIRS component values were specified a priori (as done by the PRAM developers) and corresponded to those of the PRAM to facilitate comparative assessment of performance.1 Each score was calculated on presentation and after 2 hours of treatment. Predictor variables were baseline PRAM and AAIRS and change of each score after 2 hours of treatment (ΔPRAM, ΔAAIRS). Criterion standard outcome variables used to examine discrimination and responsiveness of each score were percent-predicted forced expiratory volume in 1-second (%FEV1) and 2-hour proportionate change expressed as percent (Δ%FEV1) in those who could perform this test at each time point. We performed linear regression of baseline %FEV1 on baseline PRAM or AAIRS in two separate models. In two other models, Δ%FEV1 was regressed on ΔPRAM or ΔAAIRS, baseline %FEV1, and the baseline value of the corresponding score. Linear spline functions were used in both sets of models to allow for nonlinear relationships between each predictor and the respective outcome. Ninety-five percent confidence intervals (95% CI) were calculated using bootstrap resampling techniques with 1,000 replications. The study protocol was approved by our institutional IRB. Of 661 unique subjects, median [IQR] age was 8.8 [6.9, 11.3], 60% were male, and 59% were African-American. Accessory muscle use was visually observed in: Scalene, 2 (0.3%); sternocleidomastoid, 362 (55%); intercostal, 110 (17%); and subcostal, 113 (17%). Prolonged expiratory phase was noted in 329 (50%) and severely prolonged expiratory phase in 45 (7%). Baseline scores were: PRAM 4 [1, 5], range 0–9 (SD 2.32); AAIRS 5 [1, 8], range 0–14 (SD 3.53). Baseline %FEV1 was 51 [36, 72; n = 430] and Δ%FEV1 27 [9.6, 62; n = 282]. Both scores discriminated baseline severity assessed using %FEV1 (n = 430): PRAM, R2 0.44 (95% CI, 0.37–0.51); AAIRS, R2 0.47 (95% CI, 0.41–0.51). In addition, the adjusted models that included change of each score demonstrated responsiveness in predicting Δ%FEV1 (n = 282): ΔPRAM, R2 0.28 (95% CI, 0.17–0.37); ΔAAIRS, R2 0.28 (95% CI, 0.18–0.34). The AAIRS demonstrates discrimination and responsiveness comparable to the PRAM. Scalene retractions were observed rarely, whereas intercostal and subcostal retractions and expiratory phase prolongation were observed frequently, accounting for the greater range and variability (SD 3.53 vs. 2.32) of AAIRS. The greater range of values of the AAIRS, which substitutes relevant signs we have found to be easier to identify, might provide more comprehensive assessment of acute asthma exacerbation severity for research protocols.2

Triage Nurse Initiation of Corticosteroids in Pediatric Asthma Is Associated With Improved Emergency Department Efficiency

To assess the effectiveness of nurse-initiated administration of oral corticosteroids before physician assessment in moderate to severe acute asthma exacerbations in the pediatric ED. A time-series controlled trial evaluated nurse initiation of treatment with steroids before physician assessment in children with Pediatric Respiratory Assessment Measure score ≥4. One-to-one periods (physician-initiated and nurse-initiated) were analyzed from September 2009 through May 2010. In both phases, triage nurses initiated bronchodilator therapy before physician assessment, per Pediatric Respiratory Assessment Measure score. We reviewed charts of 644 consecutive children aged 2 to 17 years for the following outcomes: admission rate; times to clinical improvement, steroid receipt, mild status, and discharge; and rate of return ED visit and subsequent admission. Nurse-initiated phase children improved earlier compared to physician-initiated phase (median difference: 24 minutes; 95% confidence interval [CI]: 1-50; P = .04). Admission was less likely if children received steroids at triage (odds ratio = 0.56; 95% CI: 0.36-0.87). Efficiency gains were made in time to steroid receipt (median difference: 44 minutes; 95% CI: 39-50; P < .001), time to mild status (median difference: 51 minutes; 95% CI: 17-84; P = .04), and time to discharge (median difference: 44 minutes; 95% CI: 17-68; P = .02). No differences were found in return visit rate or subsequent admission. Triage nurse initiation of oral corticosteroid before physician assessment was associated with reduced times to clinical improvement and discharge, and reduced admission rates in children presenting with moderate to severe acute asthma exacerbations.

Early Administration of Systemic Corticosteroids Reduces Hospital Admission Rates for Children With Moderate and Severe Asthma Exacerbation

The variable effectiveness of clinical asthma pathways to reduce hospital admissions may be explained in part by the timing of systemic corticosteroid administration. We examine the effect of early (within 60 minutes [SD 15 minutes] of triage) versus delayed (>75 minutes) administration of systemic corticosteroids on health outcomes. We conducted a prospective observational cohort of children aged 2 to 17 years presenting to the emergency department with moderate or severe asthma, defined as a Pediatric Respiratory Assessment Measure (PRAM) score of 5 to 12. The outcomes were hospital admission, relapse, and length of active treatment; they were analyzed with multivariate logistic and linear regressions adjusted for covariates and potential confounders. Among the 406 eligible children, 88% had moderate asthma; 22%, severe asthma. The median age was 4 years (interquartile range 3 to 8 years); 64% were male patients. Fifty percent of patients received systemic corticosteroids early; in 33%, it was delayed; 17% of children failed to receive any. Overall, 36% of patients were admitted to the hospital. Compared with delayed administration, early administration reduced the odds of admission by 0.4 (95% confidence interval 0.2 to 0.7) and the length of active treatment by 0.7 hours (95% confidence interval -1.3 to -0.8 hours), with no significant effect on relapse. Delayed administration was positively associated with triage priority and negatively with PRAM score. In this study of children with moderate or severe asthma, administration of systemic corticosteroids within 75 minutes of triage decreased hospital admission rate and length of active treatment, suggesting that early administration of systemic corticosteroids may allow for optimal effectiveness.

The RAD score: a simple acute asthma severity score compares favorably to more complex scores

Acute asthma severity scores facilitate assessment and implementation of timely and appropriate therapy for pediatric patients but are complex and challenging for clinicians to use at the bedside. To assess whether a simple, bedside acute asthma severity score comprising 3 standard clinical measures performs as well as more comprehensive asthma scores. We prospectively enrolled participants 5 to 17 years of age with acute asthma exacerbations. We recorded 3 asthma scores at baseline and after 2 hours of treatment: the Pediatric Asthma Severity Score (PASS), the Pediatric Respiratory Assessment Measure (PRAM), and the RAD score (Respiratory rate; Accessory muscle use; Decreased breath sounds). We assessed each score for criterion validity in predicting baseline percent forced expiratory volume in 1 second (%FEV(1)) and for responsiveness in predicting change of %FEV(1) after 2 hours of treatment using multiple linear regression models adjusted for age, race, sex, and Global Initiative for Asthma chronic control. Of 536 participants included for analyses, median age was 8.8 years, 60% were male, and 58% were African American. The 3 acute asthma scores demonstrated similar criterion validity to explain variation of baseline %FEV(1) (R(2): 0.434 [PASS]; 0.462 [PRAM]; 0.426 [RAD]), but none demonstrated clinically significant responsiveness to change in %FEV(1) (R(2): 0.109 [PASS]; 0.106 [PRAM]; 0.139 [RAD]). The RAD score, comprising 3 routinely measured bedside clinical parameters, is a simple and easily used instrument for assessing the severity of an acute asthma exacerbation and has comparable criterion validity and improved responsiveness when compared with 2 more complex acute asthma scores.

Adherence to Pediatric Asthma Guidelines in the Emergency Department: A Survey of Knowledge, Attitudes and Behaviour among Health Care Professionals

Despite strong evidence for using clinical care pathways to manage acute pediatric asthma, adherence remains suboptimal. To elicit information from health care professionals regarding their knowledge, attitudes and use of a care pathway for acute childhood asthma. A cross-sectional, self-administered survey of physicians, nurses and respiratory therapists who worked in the emergency department at the Montreal Children's Hospital (Montreal, Quebec) from August to December 2007 was conducted. The survey assessed knowledge, attitude toward and agreement with the care pathway, as well as its use four years after its implementation. Of the 128 health care professionals surveyed, 72 (56%) responded. Of these, 99% reported being familiar with the pathway, more than 90% agreed with its use for mild and moderate asthma, while 79% agreed with its use for severe asthma. For 99% of health care professionals, the advantages of using the pathway outweighed the disadvantages; however, 64% admitted to making variations to the pathway. Although 92% of respondents reported that they were quite comfortable with using the asthma severity Pediatric Respiratory Assessment Measure, only 53% and 36% correctly identified the severity score cut-offs for moderate and severe asthma, respectively. Seventeen per cent of respondents underestimated the delay of onset of action of oral corticosteroids, while 36% of physicians incorrectly believed that a higher than necessary dose was recommended for ipratropium bromide. Results of the survey confirmed that the health care professionals queried had a positive attitude toward the pediatric asthma care pathway. Knowledge gaps and the balance between standardization versus individualization of care may be key elements to explain suboptimal adherence to the pathway.

Can Montelukast Shorten Prednisolone Therapy in Children with Mild to Moderate Acute Asthma? A Randomized Controlled Trial

To examine whether outpatient post-stabilization therapy with montelukast produces more treatment failures than prednisolone. In this randomized, double-blind, double-dummy non-inferiority trial, 130 children 2 to 17 years of age with mild to moderate acute asthma stabilized with prednisolone in the emergency department received 5 daily treatments with either prednisolone or montelukast after discharge. The primary outcome was treatment failure within 8 days (ie, an asthma-related unscheduled visit, hospitalization, or additional systemic corticosteroids). The rates of treatment failure were 7.9% in the prednisolone group and 22.4% in the montelukast group (95% CI, 26.5%-2.4%). Treatment was more likely to fail in younger patients (odds ratio, 4.9). In the montelukast group, more patients received additional pharmacotherapy than in patients receiving prednisolone (23.9% versus 9.5%, P = .03). The differences in the daily salbutamol treatments, asymptomatic days, and changes in the Pediatric Respiratory Assessment Measure score were not significant (P = .85, .75, and .26, respectively). Montelukast does not represent an adequate alternative to corticosteroids after outpatient stabilization in mild to moderate acute asthma. This population should receive oral corticosteroids after discharge.

The pediatric respiratory assessment measure (PRAM)

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

The Pediatric Respiratory Assessment Measure: A Valid Clinical Score for Assessing Acute Asthma Severity from Toddlers to Teenagers

To determine the performance characteristics of the Preschool Respiratory Assessment Measure (PRAM) in preschool and school-aged children with acute asthma. In a prospective cohort study, we examined the validity, responsiveness, and reliability of the PRAM in children aged 2 to 17 years with acute asthma. The study involved more than 100 nurses and physicians who recorded the PRAM on triage, after initial bronchodilation, and at disposition. Predictive validity and responsiveness were examined using disposition as outcome. The PRAM was recorded in 81% (n = 782) of patients at triage. The PRAM at triage and after initial bronchodilation showed a strong association with admission (r = 0.4 and 0.5, respectively; P < .0001), thus supporting its ability to distinguish across severity levels. The responsiveness coefficient of 0.7 indicated good ability to identify change after bronchodilation. The PRAM showed good internal consistency (Cronbach alpha = 0.71) and inter-rater reliability (r = 0.78) for all patients and across all age groups. Good performance characteristics were observed in all age groups, making the PRAM an attractive score for assessing asthma severity and response to treatment.